Rate Of Chronic Lung Disease Research Articles

Outcomes of ST-Elevation Myocardial Infarction in Patients With Opioid Dependence: A National Inpatient Sample Study.

ST-segment elevation myocardial infarction (STEMI) is a critical condition characterized by the sudden obstruction of one or more coronary arteries, resulting in diminished blood flow to the heart muscle. This acute ischemic event demands swift and precise intervention to minimize myocardial damage and preserve cardiac function. Opioids, a class of potent analgesic medications, are frequently utilized in the management of STEMI-related chest pain. Despite their efficacy in alleviating discomfort, their use in this context warrants careful consideration due to potential adverse effects and interactions. Methods: In this large nationwide retrospective observational study, we evaluated the effect of opioid dependence on inpatient mortality, length of hospitalization, and cost of hospitalization of patients with STEMI. Data was collected for 2019 from various hospitals across the United States using the National Inpatient Sample (NIS) through the Healthcare Cost and Utilization Project (HCUP). Using the International Classification of Diseases-10 codes (ICD-10), we identified a primary diagnosis of STEMI in patients over the age of 18, as well as a secondary diagnosis of opioid dependence. Complex samples and multivariable logistic and linear regression models were used to determine the association of opioid dependence on inpatient mortality, length of hospitalization, and cost of hospitalization of patients with STEMI. Of the patients who fit our criteria, we identified other comorbidities and diagnoses associated with them as potential confounders including drug abuse, hypertension, diabetes, alcohol use, obesity, peripheral vascular disease, and chronic lung disease. Other confounders thatwere adjusted for include race, Charlson Comorbidity index, median household income,insurance, hospital region in the US, hospital bed size, and teaching status of the hospital. Results: A total of 661,990 patients presented to a hospital with a primary diagnosis of STEMI in 2019. The majority of the patients were malewith a mean age of 62.5+/-3.4 and were Caucasian American. Patients who were opioid dependent were found to be on average younger, earned less than the 25th percentile household income, had a higher history of illicit drug and alcohol use, and had Medicaid. They were also found to have higher rates of chronic lung disease at 39.2%, compared to 21.4.% in patients who were not opioid-dependent. Patients who were not opioid dependent were found to have higher rates of hypertension and type 2 diabetes mellitus. Inpatient mortality and cost of hospitalization in STEMI patients with opioid dependence were not statistically different compared to those who were not opioid dependent. However, STEMI patients who were opioid dependent did have an associated longer length of hospitalization. Conclusion: Opioid use for pain relief in acute coronary syndrome, particularly STEMI, is a mainstay of treatment. Our retrospective cohort dived into assessing the relationship between opioid dependence on its effect on inpatient mortality, length of stay, and cost of hospitalization in STEMI patients. Our study showed that opioid dependence has no significant impact on inpatient mortality. However, it was associated with a longer length of hospital stay in STEMI patients. Further studies may be warranted into the effects of opioid dependence on the length of hospitalization in STEMI patients. .

The Role of the Airway and Gut Microbiome in the Development of Chronic Lung Disease of Prematurity.

Chronic lung disease (CLD) of prematurity, a common cause of morbidity and mortality in preterm-born infants, has a multifactorial aetiology. This review summarizes the current evidence for the effect of the gut and airway microbiota on the development of CLD, highlighting the differences in the early colonisation patterns in preterm-born infants compared to term-born infants. Stool samples from preterm-born infants who develop CLD have less diversity than those who do not develop CLD. Pulmonary inflammation, which is a hallmark in the development of CLD, may potentially be influenced by gut bacteria. The respiratory microbiota is less abundant than the stool microbiota in preterm-born infants. There is a lack of clear evidence for the role of the respiratory microbiota in the development of CLD, with results from individual studies not replicated. A common finding is the presence of a single predominant bacterial genus in the lungs of preterm-born infants who develop CLD. Probiotic preparations have been proposed as a potential therapeutic strategy to modify the gut or lung microbiota with the aim of reducing rates of CLD but additional robust evidence is required before this treatment is introduced into routine clinical practice.

Azithromycin therapy for prevention of chronic lung disease of prematurity (AZTEC): a multicentre, double-blind, randomised, placebo-controlled trial

Systematic reviews have reported conflicting evidence on whether macrolide antibiotics reduce rates of chronic lung disease of prematurity (CLD) in at-risk preterm infants born at less than 30 weeks' gestation, including in those colonised with pulmonary Ureaplasma spp. Since an adequately powered trial has been lacking, we aimed to assess if the macrolide azithromycin improved survival without the development of physiologically defined moderate or severe CLD in preterm infants. AZTEC was a multicentre, double-blind, randomised, placebo-controlled trial conducted in 28 tertiary neonatal intensive care units in the UK. Infants were eligible if they were born at less than 30 weeks' gestation and had received at least 2 h of either non-invasive (continuous positive airway pressure or humidified high flow nasal cannula therapy) or invasive respiratory support (via endotracheal tube) within 72 h of birth. Eligible infants were randomly allocated in a 1:1 ratio using random permuted blocks of four to receive either intravenous azithromycin at 20 mg/kg per day for 3 days followed by 10 mg/kg for 7 days, or to placebo. Allocation was stratified by centre and gestational age at birth (<28 weeks vs ≥28 weeks). Azithromycin and placebo vials were encased in tamper-evident custom cardboard cartons to ensure masking for clinicians, parents, and the research team. The primary outcome was survival without development of physiologically defined moderate or severe CLD at 36 weeks' postmenstrual age. Outcomes and safety were analysed on an intention-to-treat basis (all randomly allocated infants, regardless of any post-randomisation events). The study was registered with ISRCRN (11650227) and is closed. Infants were recruited between Oct 9, 2019, and March 22, 2022. 799 (53·1%) of 1505 eligible infants underwent random allocation; three infants were withdrawn, including consent to use their data, leaving 796 infants for analysis. Survival without moderate or severe CLD occurred in 166 (42%) of 394 infants in the intervention group and 179 (45%) of 402 in the placebo group (three-level adjusted OR [aOR] 0·84, 95% CI 0·55-1·29, p=0·43). Pulmonary Ureaplasma spp colonisation did not influence treatment effect. Overall, seven serious adverse events were reported for the azithromycin group (five graded as severe, two as moderate), and six serious adverse events were reported in the placebo group (two severe, two moderate, and two mild), as assessed by the local principal investigators. Since prophylactic use of azithromycin did not improve survival without development of physiologically-defined CLD, regardless of Ureaplasma spp colonisation, it cannot be recommended in clinical practice. UK National Institute for Health and Care Research.

Characteristics of subclinical tuberculosis compared to active symptomatic tuberculosis using nationwide registry cohort in Korea: prospective cohort study.

The clinical manifestations of tuberculosis (TB) range from asymptomatic to disseminated depending on the microbiological and immunological status, making the diagnosis challenging. To improve our understanding of the disease progression mechanism, we aimed to identify the characteristics of subclinical TB and important predictors of symptom development. From July 2018 to June 2019, we systemically collected data from the National Surveillance System of South Korea on patients with pulmonary TB, and compared the characteristics of subclinical and active symptomatic TB patients. A total of 4,636 patients with pulmonary TB were included, and the prevalence of subclinical TB was 37.1% (1,720/4,636). In subclinical TB patients, the positivity rates of acid-fast bacilli (AFB) smear and culture were 16.2 and 50.2%, respectively. Subclinical TB patients were younger (55.6 ± 19.2 vs. 60.7 ± 19.5, P < 0.001), had a higher body mass index (21.7 ± 3.1 vs. 21.0 ± 3.5, P < 0.001), less under Medicaid support, and had lower rates of chronic lung disease, AFB smear and culture positivity, and bilateral disease. Regarding the characteristic differences of individual TB-related symptoms, age was positively associated with dyspnoea and general weakness but negatively associated with chest pain, haemoptysis, and weight loss. Male patients were more prone to weight loss. Chronic lung disease was related to symptoms including cough/phlegm, dyspnoea, and haemoptysis, while autoimmune diseases were associated with fever and weight loss. The development of TB-related symptoms was associated with microbiological burden and clinical characteristics including underlying comorbidities, which should be evaluated carefully.

Trends in neonatal mortality and morbidity in very-low-birth-weight (VLBW) infants over a decade: Singapore national cohort study.

Very preterm infants are at risk for neurodevelopmental impairment because of postnatal morbidities. This study aims to (1) compare the outcomes of very-low-birth-weight (VLBW) infants in Singapore during two time periods over a decade; 2) compare performances among Singaporean neonatal intensive care units (NICUs); and 3) compare a Singapore national cohort with one from the Australian and New Zealand Neonatal Network (ANZNN). Singapore national data on VLBW infants born during two periods, 2007-2008 (SG2007, n=286) and 2015-2017 (SG2017, n=905) were extracted from patient medical records. The care practices and clinical outcomes among three Singapore NICUs were compared using SG2017 data. Third, using data from the ANZNN2017 annual report, infants with gestational age (GA) ≤29 weeks in SG2017 were compared with their Oceania counterparts. SG2017 had 9.9% higher usage of antenatal steroids (p<0.001), 8% better survival for infants ≤26 weeks (p=0.174), and used 12.7% lesser nonsteroidal anti-inflammatory drugs for patent ductus arteriosus closure (p<0.001) than those of SG2007 cohort. Rate of late-onset sepsis (LOS) was almost halved (7.4% vs. 14.0%, p<0.001), and exclusive human milk feeding after discharge increased threefold (p<0.001). SG2017, in contrast, had a higher rate of chronic lung disease (CLD) (20.0% vs. 15.1%, p=0.098). Within SG2017, the rates of LOS, CLD, and human milk feeding varied significantly between the three NICUs. When compared with ANZNN2017, SG2017 had significantly lower rates of LOS for infants ≤25 weeks (p=0.001), less necrotizing enterocolitis for infants ≤27 weeks (p=0.002), and less CLD across all GA groups. Postnatal morbidities and survival rates for VLBW infants in Singapore have improved over a decade. Outcomes for VLBW infants varied among three Singapore NICUs, which provide a rationale for collaboration to improve clinical quality. The outcomes of Singaporean VLBW infants were comparable to those of their ANZNN counterparts.

Vitamin A supplementation for the prevention of chronic lung disease in premature infants: A cost-utility analysis.

Despite the growing evidence on efficacy, little is known regarding the efficiency of Vitamin A supplementation to decrease the probability of chronic lung disease (CLD) in preterm infants. This study aims to determine the cost-utility of Vitamin A to prevent CLDin preterm infants in Colombia. A decision tree model was used to estimate the cost and quality-adjusted life-years (QALYs) of Vitamin A supplementation in preterm infants. Multiple sensitivity analyses were conducted to evaluate the robustness of the model. Cost-effectiveness was evaluated at a willingness-to-payvalue of US$5180. Vitamin A was associated with lower costs and higher QALYs. The expected annual cost per patient with Vitamin A was US$1579 (95% CIUS$1555-US$1585) and without Vitamin A was US$1913 (95%CI US$1891-US$1934). The QALYs per person estimated with Vitamin A was 0.66 (95%CI 0.66-0.67) and without Vitamin A was 0.61 (95%CI 0.60-0.61). This position of absolute dominance (Vitamin A has lower costs and higher QALYs than without Vitamin A) is unnecessary to estimate the incremental cost-effectiveness ratio. Our economic evaluation shows that Vitamin A is cost-effective to reduce the incidence rate of CLD in premature infants in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Implementation of Bubble Continuous Positive Airway Pressure in the Delivery Room and NICU.

Implementation of Bubble Continuous Positive Airway Pressure in the Delivery Room and NICU.

The effects of exposure to HIV in neonates at a referral hospital in South Africa

BackgroundFewer infants are infected with HIV through mother-to-child transmission, making HIV-exposed but uninfected (HEU) infants a growing population. HIV-exposure seems to affect immunology, early growth and development, and is associated with higher morbidity and mortality rates. Currently, there is a lack of information regarding the clinical effects of HIV-exposure during the neonatal period.ObjectivesTo identify a possible difference in mortality and common neonatal morbidities in HEU neonates compared to HIV-unexposed neonates.MethodsThis was a retrospective, descriptive study of all neonates admitted to the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital between 1 January 2017 and 31 December 2018. HEU neonates were compared to HIV-unexposed neonates.ResultsThere were 3236 neonates included, where 855 neonates were HEU. The HEU neonates had significantly lower birth weight and gestational age. The HEU neonates had higher rates of neonatal sepsis (19.8% vs 14.2%, OR 1.49, p < 0.001), specifically for late onset sepsis, and required more respiratory support. NCPAP and invasive ventilation was more common in the HEU group (36.3% vs 31.3% required NCPAP, p = 0.008, and 20.1% vs 15,0% required invasive ventilation, p < 0.001). Chronic lung disease was more common among HIV-exposed neonates (12.2% vs 8.7%, OR 1.46, p = 0.003). The difference in mortality rates between the study groups was not significant (10.8% of HEU neonates and 13.3% of HIV-unexposed).ConclusionsHEU neonates had higher rates of neonatal sepsis, particularly late-onset sepsis, required more respiratory support and had higher rates of chronic lung disease. Mortality of HEU neonates was not different HIV-unexposed neonates.

A Quality Improvement Initiative to Reduce Bronchopulmonary Dysplasia in a Level 4 NICU—Golden Hour Management of Respiratory Distress Syndrome in Preterm Newborns

Background: Prevention of chronic lung disease (CLD) requires a multidisciplinary approach spanning from the delivery room to Neonatal Intensive Care Unit (NICU) discharge. In 2018, a quality improvement (QI) initiative commenced in a level 4 NICU with the goal of decreasing chronic lung disease rates below the Vermont Oxford Network (VON) average of 24%. Methods: Improvement strategies focused on addressing the primary drivers of ventilation strategies, surfactant administration, non-invasive ventilation, medication use, and nutrition/fluid management. The primary outcome was VON CLD, defined as need for mechanical ventilation and/or supplemental oxygen use at 36 weeks postmenstrual age. Statistical process control charts were used to display and analyze data over time. Results: The overall CLD rate decreased from 33.5 to 16.5% following several interventions, a 51% reduction that has been sustained for >18 months. Changes most attributable to this include implementation of the “golden hour” gestational age (GA) based delivery room protocol that encourages early surfactant administration and timely extubation. Fewer infants were intubated across all GA groups with the largest improvement among infants 26–27 weeks GA. Conclusions: Our efforts significantly decreased CLD through GA-based respiratory guidelines and a comprehensive, rigorous QI approach that can be applicable to other teams focused on improvement.

Respiratory morbidity, healthcare resource use, and cost burden associated with extremely preterm birth in The Netherlands

Background Extremely preterm (EP) infants have high rates of respiratory morbidity and correspondingly high healthcare resource utilization. Objectives Data from the PHARMO Perinatal Research Network were analyzed to quantify the burden of EP birth in the Netherlands. Methods A retrospective analysis included infants <28 weeks gestational age with a birth record in the Perinatal Registry (1999–2015) and data in the PHARMO Database Network. Outcomes of interest included select comorbidities, hospital readmissions, and costs of hospitalization and medication up to 1- and 2-years corrected age. Outcomes were stratified by birth period (1999–2005, 2000–2009, 2010–2015) and by diagnosis of bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD). Results The cohort included 168 EP infants (37 born 1999–2005, 51 born 2006–2009, 80 born 2010–2015). Median (Q1–Q3) birth weights decreased by birth period from 970 (840–1,035) g in 1999–2005 to 853 (695–983) g in 2010–2015. Overall, BPD and CLD were reported during the birth hospitalization in 40% and 29% of infants, respectively; rates of BPD increased and rates of CLD decreased by birth period. Eighty-four percent of EP infants had an additional comorbidity. Mean (standard deviation) costs of birth hospitalization were €110,600 (€73,000) for 1999–2005, €119,350 (€60,650) for 2006–2009, and €138,800 (€130,100) for 2010–2015. Birth hospitalization and total costs for up to 1- and 2-years corrected age were higher for infants with BPD and/or CLD than for those without either complication. Conclusion Healthcare resource utilization and costs for EP infants, especially for those with respiratory morbidities, increased between 1999 and 2015. Future cost-effectiveness analyses are essential to determine the economic impact of this change and underscore the need for new therapeutic interventions to decrease clinical sequelae in this vulnerable population.

Abstract 16871: Hypertensive Diseases of Pregnancy Are Associated With Longer Delivery Stays and Rehospitalizations

Introduction: Hypertensive diseases of pregnancy (HDP) are common, and are associated with significant short- and long-term cardiovascular morbidity and mortality, but less is known about their association with post-delivery health care utilization. We sought to assess the association of HDP with 90-day post-delivery unplanned hospital revisits (ED visits, observation stays, and readmissions) in a broad cohort of pregnant women. Methods: Retrospective cohort study. Women who delivered from 1/1/2019-12/31/2019 at a large urban hospital were identified using diagnosis related groups. Women with HDP, including eclampsia, preeclampsia, and gestational hypertension were identified using standard ICD-10-CM codes. Logistic regression, controlling for 29 Elixhauser comorbidities including lung disease, obesity, depression, drug use, thyroid disease, renal disease, and others, was used to determine the independent association of HDP with unplanned hospital revisits. Results: Out of 3,391 deliveries, 1,225 (36.1%) mothers had HDP. Women with HDP were of similar age and insurance status as those without, but had higher rates of chronic lung disease (19.4% versus 13.5%), obesity (22.7% versus 7.8%), depression (15.8% versus 11.0%), and drug use (13.8% versus 9.9%, p for all &lt;0.001). Mothers with HDP had longer lengths of stay for their delivery visits (4.7 vs. 3.5 days, p&lt;0.001), and a higher percentage had 1 or more 90-day hospital revisits (42.4% versus 33.1%, p&lt;0.001) than those without HDP. After controlling for comorbidities and insurance coverage, hypertensive disease remained independently associated with 90-day unplanned hospital revisits (odds ratio 1.24, 95% CI [1.06, 1.45], p=0.007). Conclusions: HDP is associated with a high rate of underlying chronic disease and contributes to excess delivery hospitalization days and rehospitalization rates. Novel strategies are required to optimize post-partum care and inter-pregnancy health for this common condition.

Impact of Sickle Cell Trait on Morbidity and Mortality from Sars-Cov-2 Infection

Introduction: The high morbidity and mortality of SARS-CoV-2 in Blacks or African American in the United States is well established. Individuals with sickle cell trait (SCT), who are mostly Black or African American, have adverse health outcomes in situations of increased physiologic stress. The novel corona virus SARS-CoV-2 causes a severe multi-systemic viral infection that induces intense inflammation and metabolic derangements that can exacerbate RBC sickling and organ damage. The purpose of this study is to evaluate the impact of SCT status on the outcome of patients hospitalized for SARS-CoV-2.Methods: We conducted a multi-center, IRB-approved, retrospective analysis of Black/African American patients who were admitted for management of SARS-CoV-2 infection from March 24, 2020 to June 2, 2020. Patients were identified using an electronic medical record (EMR) report that selected for race as “Black or African American” and a positive SARS-CoV-2 PCR test during that admission. We excluded patients admitted for reasons other than SARS-CoV-2 infection and reviewed only the in-hospital experience. Patient demographics, co-morbidities, admission laboratory values, complications of SARS-CoV-2 infection, and status on discharge were abstracted by manual chart review. High performance liquid chromatography (HPLC) was performed on discarded blood of patients to test for sickle cell trait. The primary objective was to evaluate the impact of SCT status on morbidity outcomes of Blacks/African Americans hospitalized with SARS-CoV-2 infection. Categorical data were tested using the Fisher exact test, and quantitative data were tested using the Wilcoxon rank sum test. Testing was done at the nominal 0.05 two-sided significance level.Results: One hundred and sixty-six Black or African American patients admitted for SARS-CoV-2 infection are included in the analysis. Twenty patients had SCT, 143 had normal hemoglobin (AA) and 3 had hemoglobin C trait (AC). The 146 patients with AA and AC hemoglobin were pooled together. Patient demographics, comorbidities, and lab values on admission by SCT status are shown in Table 1. Complications of SARS-CoV-2 by SCT status is shown in Table 2. Among Black or African American patients admitted for SARS-CoV-2 in this study, SCT represented 12.0% of the total. At the time of admission, individuals with SCT had significantly higher creatinine (p=0.004) but were less likely to present with a history of chronic lung disease (p=0.004). However, a history of chronic lung disease was not in itself associated with death in hospital, p=0.056, and creatinine at admission was not associated with death, p=0.483. Correspondingly, a total of 19 of the 146 patients without SCT died in the hospital (13%), compared to 3 of 20 SCT patients (15%), Fisher exact test p-value = 0.732, despite the difference in the groups at admission.Discussion: The higher morbidity and mortality from SARS-CoV-2 infection in Black or African Americans is well-documented. This study showed equivalent outcomes in patients admitted for SARS-CoV-2 infection whether, or not they had SCT. There was a lower rate of chronic lung disease in patients with SCT, but no difference in respiratory outcome from SARS-CoV-2 between the groups. Patients with SCT also had worse creatinine at presentation but there was no difference in hospital death or end organ complications at discharge. Notably, individuals with SCT made up 12% of Black patients admitted for SARS-CoV-2 in this study which is higher than the reported prevalence of SCT of 7.31% in the African American population (p=0.025), but this is of unclear significance. Our study is limited by the restriction to one metropolitan area and by being retrospective in nature, but the initial data suggests that those with SCT may be more frequently admitted to hospital when infected by SARS-CoV-2 than individuals without SCT. A larger prospective study across multiple regions of the United States should be considered to further assess the prevalence of SARS-CoV-2 in the African American community and the apparent increased rate of hospitalizations for SARS-CoV-2 infection in individuals with SCT.DisclosuresNeuberg:Madrigak Pharmaceuticals: Current equity holder in publicly-traded company; Celgene: Research Funding; Pharmacyclics: Research Funding. Achebe:Global Blood Therapeutics: Other: Advisory Board; Fulcrum Pharmaceuticals: Consultancy; Pharmacosmos: Other: Advisory Board.

Quality improvement to reduce chronic lung disease rates in very-low birth weight infants: high compliance with a respiratory care bundle in a small NICU.

Reduce chronic lung disease by 10% among very-low birth weight infants by implementing a consistent respiratory care bundle. Prospective quality improvement study of infants below 32 weeks gestation in a small neonatal intensive care unit. A respiratory care bundle to eliminate inter-provider variability and minimize use of mechanical ventilation was implemented. This included: defining delivery room management with use of continuous positive airway pressure/nasal intermittent positive pressure ventilation, uniform intubation/extubation criteria, and standardizing ventilation/post-extubation support. A total of 107 very-low birth weight infants were included in this project. Compliance with the respiratory care bundle was >90%. Chronic lung disease rates at 36 weeks postmenstrual age fell from 43 to 12% (P = 0.0006), rates of combined chronic lung disease/death decreased from 50 to 20% (P = 0.002, OR = 0.25, 95% CI 0.1-0.6), rates of severe intraventricular hemorrhage decreased from 13 to 0% (P = 0.005), and surgical ligation of patent ductus arteriosus decreased from 35 to 3% (P < 0.0001). High compliance with the respiratory care bundle was achieved and a 73% reduction in chronic lung disease rates in very-low birth weight infants occurred.

Progression to Stage D Heart Failure Among Outpatients With Stage C Heart Failure and Reduced Ejection Fraction

ObjectivesThis study sought to estimate the rate of progression to Stage D heart failure (HF) among outpatients with Stage C HF and to identify risk factors for progression. BackgroundThe pool of patients who may be candidates for advanced HF therapies is growing. MethodsWe estimated 3-year progression to clinically determined Stage D HF and competing mortality among 964 outpatients with Stage C heart failure with reduced ejection fraction (HFrEF), where ejection fraction is ≤40%. ResultsThe mean age of patients was 62 ± 15 years; 35% were women; 47% were white; 46% were black, and 7% were of other races; median baseline ejection fraction was 28% (25th to 75th percentile: 20% to 35%); and 47% had ischemic heart disease. After 3.0 years (25th to 75th percentile: 1.7 to 3.2 years), 112 patients progressed to Stage D (3-year incidence: 12.2%; 95% confidence interval [CI]: 10.2% to 14.6%; annualized: 4.5%; 95% CI: 3.8% to 5.5%), and 116 patients died before progression (3-year competing mortality: 12.9%; annualized: 4.7%; 95% CI: 3.9% to 5.6%). By 3 years, 25.1% of patients (95% CI: 22.2% to 28.1%) had either progressed to Stage D or died (annualized: 9.2%; 95% CI: 8.1% to 10.5%). Annualized progression rates were higher in black versus white patients (6.3% vs. 2.7%, respectively; p < 0.001), nonischemic versus ischemic patients (6.1% vs. 2.9%, respectively; p < 0.001), and in New York Heart Association functional class III to IV versus I to II patients (7.5% vs. 1.9%, respectively; p < 0.001) but were similar for men and women (4.7% vs. 4.2%, respectively; p = 0.53). Lower ejection fraction and blood pressure, renal and hepatic dysfunction, and chronic lung disease rates were additional predictors of progression. Predictors of competing mortality were different from those of disease progression. ConclusionsAmong patients with Stage C HFrEF receiving care in a referral center, 4.5% progressed to Stage D HF each year, with earlier progression among black and nonischemic patients. These findings have implications for healthcare planning and resource allocation for these patients.

Impact of intrauterine growth restriction on preterm lung disease.

Intrauterine growth restriction (IUGR) is an important cause for prematurity and adversely influences prematurity-related morbidities. This study evaluates the impact of IUGR on respiratory outcomes in infants <32 weeks with IUGR and birthweight <10th centile (SGA) compared to matched appropriate for gestation (AGA) controls. The primary outcomes of this retrospective study are short-term pulmonary outcomes of chronic lung disease (CLD), CLD or death, and need for home oxygen at discharge. Subgroup analysis by gestation-based stratification (<28 and ≥28 <32 weeks) was decided a priori. Total of 153 IUGR and 306 non-IUGR infants were enrolled. The rate of CLD (45% vs. 17%, p = 0.0001), death (16% vs. 4.6%, p = 0.0001), CLD or death (46% vs. 21.5%, p = 0.0001), home oxygen rates (13.7% vs. 6.5%, p = 0.01) and duration of respiratory support was significantly higher in the IUGR group. IUGR emerged as the strongest predictor of CLD (adjusted OR, 95%CI: (8.4 [2, 35]) and CLD or death (12.7 [3, 54]) across all gestation. IUGR is a major risk factor for adverse short-term pulmonary outcomes as reflected by higher rates of CLD, CLD or death, and oxygen dependency at discharge in preterm infants.

Effect of delayed cord clamping (DCC) on breathing and transition at birth in very preterm infants

BackgroundThe effects of delayed cord clamping (DCC) on transition in preterm infants are important as this procedure is becoming increasingly recommended. The aim of this study was to compare the effects of DCC with an historical cohort. MethodIn this observational study, outcomes for infants ≤29weeks were compared with a group born before the introduction of DCC. The intended intervention was DCC for 40s. Primary outcomes were the need for resuscitation and intubation in infants undergoing DCC, whilst taking note of their breathing during the procedure. Neonatal morbidities were analysed, including the association between breathing during DCC and outcome. ResultsThere were 62 infants in the DCC group, and 62 who received immediate cord clamping (ICC). Maternal and infant characteristics including gestational age (p=0.76) and birth weight (p=0.74) between groups were not significantly different. 70% of the DCC group breathed regularly at birth. Comparing the DCC and ICC groups, there was no significant difference in 1min and 5min Apgar scores or in the number requiring intubation at birth (p=0.88). Likewise, admission temperatures were similar (p=0.57). There was a significant increase in the rate of chronic lung disease in the DCC group (p=0.013). When comparing the infants who breathed during DCC with the non-breathers; the non-breathing group was more likely to be intubated (p=0.01), have chronic lung disease (p=0.02), and severe intraventricular haemorrhage (p=0.02). ConclusionDCC in these very preterm infants was well tolerated and the majority established spontaneous respiration whilst DCC was occurring. Infants who did not breathe during DCC had worse outcomes.

Does timing of initial surfactant treatment make a difference in rates of chronic lung disease or mortality in premature infants? An observational regional study

Objective: To compare two treatment strategies in preterm infants with or at risk of respiratory distress syndrome: early surfactant administration (within one hour of birth) versus late surfactant administration, in a geographically defined population.Outcome: The primary outcome was chronic lung disease (CLD) and mortality before/at 36 weeks. Secondary outcomes included: duration of mechanical ventilation and continuous positive airway pressure (CPAP), post-natal steroids for CLD and major neonatal morbidities.Subjects: Premature infants born at 22–32 weeks’ gestation between January 2006 and December 2009.Setting: Ten neonatal intensive care units (NICUs) in New South Wales (NSW) and Australian Capital Territory (ACT), Australia.Design: Retrospective analysis of prospectively collected data from the regional NICU database in NSW and ACT.Results: Of the 2170 infants who received surfactant, 1182 (54.5%) and 988 (45.5%) received early and late surfactant, respectively. The early surfactant group was less mature (27.1 ± 2.1 versus 29.4 ± 2.1 weeks) and had more CLD and mortality (40.2% versus 20.0%). The multivariable analysis showed early surfactant to be associated with less duration of ventilation, longer duration of CPAP and longer hospital stay but had little or no impact on CLD/mortality.Conclusion: Early surfactant administration is associated with shorter duration of ventilation but does not appear to be significantly protective against CLD/mortality among premature infants. This may support the growing evidence for consideration of CPAP as an alternative to routine intubation and early surfactant administration. Further investigation from large randomized clinical trials is warranted to confirm these results.

Effect of Maintenance Tocolysis With Nifedipine in Threatened Preterm Labor on Perinatal Outcomes

Preterm birth is the most common cause of neonatal morbidity and mortality worldwide and is associated with long-term burdens. The effectiveness of maintenance tocolysis on pregnancy and perinatal outcomes has not been demonstrated. This multicenter, double-blind, placebo-controlled trial was designed to evaluate the effectiveness of maintenance tocolysis with nifedipine on perinatal outcome. Eligible women had threatened preterm labor at 26 to 32 weeks’ gestation and had not delivered after a 48-hour course of tocolytics and corticosteroids. Study medication was 20 mg nifedipine slow-release tablets every 6 hours, for a total daily dose of 80 mg nifedipine, or placebo. The medication was given 48 to 72 h after the start of initial tocolysis and was phased out from day 10 until day 12 and discontinued on day 13. The primary outcome was a composite of adverse perinatal outcomes due to premature birth. Secondary outcomes were gestational age at delivery, birth weight, days using ventilation support, length of stay in neonatal intensive care unit, and total days in hospital until 3-month corrected age. Exploratory analyses examined prolongation of pregnancy, maternal mortality, maternal blood loss, and infant respiratory distress syndrome. Of 636 eligible women, 406 agreed to participate; 201 received nifedipine, and 205 received placebo. Mean gestational age at randomization was 29.2 weeks for both groups. Adverse perinatal outcomes occurred in 24 cases (11.9%) in the nifedipine group and 28 (13.7%) in the placebo group; perinatal death occurred in 5 (2.5%) and 4 cases (2.0%), respectively. Rates of chronic lung disease, proven neonatal sepsis, intraventricular hemorrhage greater than grade 2, periventricular leukomalacia greater than grade 1, and necrotizing enterocolitis were comparable in the 2 groups. Mean gestational ages at delivery were 34.1 and 34.2 weeks for the nifedipine and placebo groups, respectively. Birth weights did not differ significantly between the 2 groups. Neonatal intensive care unit admission occurred in 100 (40.8%) of 245 neonates in the nifedipine group and in 102 of 257 (39.7%) in the placebo group; neonatal intensive care unit and hospital stays were 10 and 23 days for both groups. The nifedipine and placebo infants required ventilation support for 2 and 3 days, respectively. Women in the 2 groups randomized at different gestational ages had no differences in perinatal mortality, composite adverse perinatal outcome, gestational age at delivery, or birth weight. Delivery before 32 weeks’ gestation occurred in 66 women (32.8%) given nifedipine and 71 women (34.6%) receiving placebo. Infant respiratory distress syndrome treated with surfactant occurred in 12 pregnancies (6.0%) in the nifedipine group and 14 (6.8%) in the placebo group. No mother in either group died. Cesarean deliveries were performed in 26.4% of women given nifedipine and 27.3% of those given placebo. Severe blood loss of more than 1000 mL occurred 11.1% and 7.3% in the nifedipine and placebo groups, respectively. Compared with placebo, nifedipine maintenance tocolysis for 12 days did not significantly reduce adverse perinatal outcomes. The etiology of preterm labor is multifaceted such that future research should investigate therapies targeted to the specific underlying causes of preterm labor.

Ureaplasma Urealyticum and Mycoplasma Hominis Colonization and Chronic Lung Disease in Preterm Neonates Under Ventilation

Background: Ureaplasma urealyticum (U. urealyticum) and Mycoplasma hominis (M. hominis) are two important pathogens in neonatal respiratory tract infections. As low gestational age and birth weight increase the colonization rate with these pathogens, and they are also risk factors of chronic lung disease (CLD), it is difficult to establish a statistically significant relation between these two factors. Objectives: To determine the colonization rate of preterm ventilated neonates with U. urealyticum and M. hominis , and the relationship between infection and chronic lung disease in these neonates, a prospective study was performed. Patients and Methods: Determining tracheal colonization rate of preterm neonates with ureaplasma and mycoplasmsa and its relation to CLD. In a cohort prospective study in Hazrat Rasoul Akram Hospital, with 62 ventilated neonates (< 35 weeks) in the first 24 h of life, where tracheal secretions were aspirated, transported, and cultured in a specific media. CLD was diagnosed as oxygen requirement at 28 days or 36 weeks post conceptional age. Results: From 62 cultures, 7 were positive for U. urealyticum (11.3%, CI95%: 3.4-19.2%) and 3 were positive for M. hominis (4.8%, CI95%: 0-10.2%). From 53 neonates who were alive at 28 days after birth, 11 neonates needed oxygen (20.8%, CI95%: 9.8-31.7%). From 10 neonates with positive cultures, 2 (20%, CI95%: 0-44.8%) died, and from 8 alive neonates, 3 (37.5%, CI95%: 4.0-71.0%) survived without CLD. From 52 neonates with negative cultures, 7 (13.5%, CI95%: 4.2-22.7%) died, and from 45 alive neonates, 39 (86.7%, CI95%: 76.7-96.6%) survived without CLD, and there was a significant difference between neonatal groups with positive and negative tracheal culture progressing to CLD (62.5% vs. 13.3%) (P < 0.001) (Figure 1). Conclusions: Intrauterine infection with U. urealyticum and M. hominis leads to negative neonatal outcome and increased rate of chronic lung disease in preterm neonates (< 35 weeks).