Years Of Era Research Articles

Impact of Nighttime Cardiovascular Intensive Care Unit Staffing on Failure to Rescue and Revenue

BackgroundFailure to rescue (FTR) is mortality after at least 1 postoperative complication. We investigated the impact of nighttime intensivist staffing and FTR after cardiac surgery. MethodsWe included patients who underwent cardiac surgery to examine FTR, defined as mortality in those who experienced a Society of Thoracic Surgeons–defined major complication. Era 2 (July 2021-June 2023) and era 1 (July 2016-June 2021) were characterized by the presence and absence of nighttime intensivists staffing, respectively. Complications and FTR rates, daily intensive care unit (ICU) census, and relative value units (RVUs) were compared. ResultsAmong 5654 patients, 17% (284 of 1661) in era 2 had at least 1 complication vs 19% (769 of 3993) in era 1 (P = .057). Among patients with complications, FTR incidence was 8% (22 of 284) in era 2 vs 19% (145 of 769) in era 1 (P < .001). The daily average ICU census did not change (12.3 in era 2 vs 12.0 in era 1, P = .386). Comparing mean annual RVUs during the 2 fiscal years in era 2 (35,613 per year) with what would have been expected based on the last 2 fiscal years of era 1 (26,744 per year), a significant increase of +8870 per year was observed (95% CI, 3876-13,863, P = .028). Multivariable analyses found no difference in the risk of major complications comparing era 2 vs era 1 (odds ratio, 1.04; 95% CI, 0.89-1.23; P = .602), and a 59% reduction in FTR risk in era 2 vs era 1 (odds ratio, 0.41; 95% CI, 0.25-0.67; P < .001). ConclusionsNighttime ICU coverage reduced FTR rates in postcardiotomy patients while complication rates and ICU census remained stable. Furthermore, the increase in RVUs suggested an economically sustainable model.

Three-year outcomes after bridge to transplantation ECMO—pre- and post-2018 UNOS revised heart allocation system

BackgroundUtilization of temporary mechanical circulatory support including veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) as a bridge to heart transplantation (HT) has increased significantly under the revised United Network for Organ Sharing (UNOS) donor heart allocation system since October 2018. The revised heart allocation system aimed to lower waitlist times and mortality for the most critically ill patients requiring bi-ventricular, non-dischargeable, mechanical circulatory support. While previous reports have shown improved 1-year post-HT survival in the current Era, 3-year survival and factors associated with mortality among bridge to transplant (BTT) ECMO patients are not well described. MethodsWe queried the UNOS database for all adult (age ≥ 18 years) heart-only transplants performed between 2010 and 2019. Patients were stratified as either pre- (January 2010 to September 2018; Era 1) or post-allocation change (November 2018 to December 2019; Era 2) cohort based on their HT date. Baseline recipient characteristics and post-transplant outcomes were compared. A Cox regression analysis was performed to explore risk factors for 3-year mortality among BTT-ECMO patients in Era 2. For each Era, 3-year mortality was also compared between BTT ECMO patients and those transplanted without ECMO support. ResultsDuring the study period, 116 patients were BTT ECMO during Era 1 and 154 patients during Era 2. Baseline recipient characteristics were similar in both groups. Median age was 48 (36-58 IQR) years in Era 2 while it was 51 (27-58 IQR) years in Era 1. Majority of BTT-ECMO patients were males in both Era 2 and Era 1 (77.7% vs 71.5%, p = 0.28). Median ECMO run times while listed for HT were significantly shorter (4 days vs 7 days, p < 0.001) in Era 2. Waitlist mortality among BTT ECMO patients was also significantly lower in Era 2 (6.3% vs 19.3%, p < 0.001). Post-HT survival at 6 months (94.2% vs 75.9%, p < 0.001), 1 year (90.3% vs 74.2%, p < 0.001), and 3 years (87% vs 66.4%, p < 0.001) was significantly improved in Era 2 as compared to Era 1. Graft failure at 1 year (10.3% vs 25.8%, p = 0.0006) and 3 years (13.6% vs 33.6%, p=0.0001) was also significantly lower in Era 2 compared to Era 1. Three-year survival among BTT ECMO patients in Era 2 was similar to that of patients transplanted in Era 2 without ECMO support (87% vs 85.7%, p=0.75). In multi-variable analysis of BTT-ECMO patients in Era 2, every 1 kg/m2 increase in body mass index (BMI) was associated with higher mortality at 3 years (HR 1.09, 95% CI 1.02-1.15, p = 0.006). Similarly, both post-HT stroke (HR 5.58, 95% CI 2.57-12.14, p < 0.001) and post-HT renal failure requiring hemodialysis (HR 4.36, 95% CI 2.43-7.82, p < 0.001) were also associated with 3-year mortality. ConclusionThree years post-HT survival in patients bridged with ECMO has significantly improved under the revised donor heart allocation system compared to prior system. BTT ECMO recipients under the revised system have significantly shorter ECMO waitlist run times, lower waitlist mortality and 3-year survival similar to those not bridged with ECMO. Overall, the revised allocation system has allowed more rapid transplantation of the sickest patients without a higher post-HT mortality.

Pengaruh Permainan Kosakata Bahasa Inggris Melalui Digital Smart Board For Kids Terhadap Perkembangan Bahasa Anak Usia 5-6 Tahun di Era Merdeka Belajar

This research will use the Digital Smart Board for Kids game as a means of learning English vocabulary for young children. This study uses a type of quantitative research using a pre-experimental design with one group pretest-posttest. The research subjects in this study were 15 children aged 5-6 years. The selection of subjects takes into account the application of foreign languages, especially English in teaching and learning activities in kindergarten. Data collection techniques using observation and documentation. To draw conclusions from the research results, a hypothesis test was carried out using the t-test. Before conducting the t-test, the normality test and homogeneity test were first carried out on the research results. Where the alpha value is more than 0.05, the data is considered good and reliable. Hypothesis testing was carried out to determine the effect of English vocabulary games through the Digital Smart Board for Kids on the language development of children aged 5-6 years in the independent learning era. This Digital Smart Board game for kids can be played by all children, so that development in the classroom becomes more applicable, contextual and interesting. In conclusion, the Digital Smart Board game for kids can be used to develop children's language development properly, especially in terms of understanding, remembering and pronouncing/imitating English vocabulary in children aged 5-6 years in the era of independent learning.

Fontan Palliation in Patients with Heterotaxy Syndrome: A Five Decade Experience.

Patients with heterotaxy syndromes (right and left atrial isomerism) are at high risk of poor outcomes after single-ventricle palliation. However, the long-term outcomes and specific parameters associated with poor outcomes are incompletely understood. A retrospective review was performed of all patients with atrial isomerism who had a Fontan at our institution from 1973 to 2020. Standard demographic, as well as pre-, peri-, and postoperative parameters were collected. Features and outcomes of patients with polysplenia were compared to asplenia. Outcomes were analyzed for effect during 4 eras: (1: 1973-1984; n = 27), (2: 1985-1994; n = 93), (3: 1995-2004; n = 28), and (4: 2005-2020; n = 10). Of the 1176 patients who had a Fontan operation, 158 (14%) had a heterotaxy syndrome. The median age at the time of Fontan was 8 (9) years. Early mortality was 20% and was greater in patients with asplenia compared to polysplenia (27% vs. 12%, p = .019). But it substantially improved over time (61% in era 1 vs. 7%-10% in the more recent eras (p < .001)), as did transplant-free survival (22% at 10 years in era 1 vs. 88% in era 4, p < .001). Transplant-free survival was significantly lower in patients with asplenia versus those with polysplenia (p = .014), and patients with heterotaxy had lower survival than nonheterotaxy (p = .01). This was largely due to the asplenia group (p < .001) (hazard ratio = 3.05, p = .007). After Fontan operation, patients with heterotaxy, particularly asplenia, continue to demonstrate worse transplant-free survival than nonheterotaxy patients. Early mortality and long-term transplant-free survival have improved in more recent eras.

Pediatric Kidney Transplantation: Frameshift in Medical and Surgical Management. Does the Perioperative Setting Have an Impact on Transplant Outcome? A Single-Center Experience.

IntroductionFrameshift in medical management as well as in surgical thinking is putting the patient as a whole is the focus, rather than just the disease. To optimize the treatment of our pediatric transplant patients in our institution, we changed in 2013 the transplant program setting, treating, and operating all patients with pediatric transplant exclusively in a pediatric environment. The aim of this study was to analyze whether or not this change had an impact on patients safety, patient population, and patients and transplant outcome.MethodsIn the retrospective analysis, we compared transplant outcome of two eras. Era1 (2008–2012) solely included patients treated in the adult facilities, era 2 (2013–2017) patients were exclusively treated in the pediatric environment.ResultsThere were 53 patients with renal transplant, with era 1 (28 patients) and era 2 (25 patients). Overall mortality was 5.6%. Median recipient age at transplantation was 13.2 years in era 1 and 8.59 years in era 2, median recipient weight at transplantation was 41.7 kg in era 1 vs. 26 kg in era 2, median size 149. 5 cm (era 1) vs. 123 cm in era2 (p = 0.05). The direct recipient/donor weight ratio remained stable in both eras, for recipients below 20 kg we saw a larger weight mismatch in era 1 (0.84 vs. 0.66). In the subgroup of patients with congenital anomalies of the kidney and urinary tract (CAKUT) those were significantly younger at onset of dialysis (p < 0.001) and at time of transplantation (p < 0.001), also they were less in body weight (p < 0.01), and body size (p < 0.001), this subgroup was larger in era 2. HLA mismatch data, serum creatinine, and GFR yield comparable results in both groups. Median time to detection of DSA was 46.2 month (3.8 years).ConclusionSince children with ESRD at the time of transplant trend to be younger and smaller, it is crucial to ensure a medical environment that is able to address their particular challenges. Even in this recipient cohort, renal transplantation can be performed safely as outlined by our data.

Long-term kidney transplant graft survival—Making progress when most needed

Current short-term kidney post-transplant survival rates are excellent, but longer-term outcomes have historically been unchanged. This study used data from the national Scientific Registry of Transplant Recipients (SRTR) and evaluated 1-year and 5-year graft survival and half-lives for kidney transplant recipients in the US. All adult (≥18years) solitary kidney transplants (n=331,216) from 1995 to 2017 were included in the analysis. Mean age was 49.4years (SD +/-13.7), 60% male, and 25% Black. The overall (deceased and living donor) adjusted hazard of graft failure steadily decreased from 0.89 (95%CI: 0.88, 0.91) in era 2000-2004 to 0.46 (95%CI: 0.45, 0.47) for era 2014-2017 (1995-1999 as reference). Improvements in adjusted hazards of graft failure were more favorable for Blacks, diabetics and older recipients. Median survival for deceased donor transplants increased from 8.2years in era 1995-1999 to an estimated 11.7years in the most recent era. Living kidney donor transplant median survival increased from 12.1years in 1995-1999 to an estimated 19.2years for transplants in 2014-2017. In conclusion, these data show continuous improvement in long-term outcomes with more notable improvement among higher-risk subgroups, suggesting a narrowing in the gap for those disadvantaged after transplantation.

Toxicity and Outcomes of Autologous Stem Cell Transplant in Multiple Myeloma Patients with Renal Insufficiency: An Institutional Comparison between Two Eras

Toxicity and Outcomes of Autologous Stem Cell Transplant in Multiple Myeloma Patients with Renal Insufficiency: An Institutional Comparison between Two Eras

Colorectal cancer liver metastases (crlm) resection: Multidisciplinary specialized care increases 5-year conditional survival

Presenter: Jaime Kruger MD | Hospital das Clinicas - University of Sao Paulo Background: Half of patients bearing colorectal tumors are expected to develop liver metastases at some point of their disease. Liver resection is considered the best treatment in order to achieve long-term survival and, sometimes, cure. Along the past two decades 5-year survival has increased after liver resection, mostly due to improved surgical and oncological care. Our institution incorporated a dedicated cancer center during it`s experience on the management of CRLM and witnessed the impact of multidisciplinary specialized care on the survival of patients operated for CRLM. Beyond cumulative survival curves, conditional survival is an interesting tool as it describes expected survival during follow-up, a forward-looking information. We sought to evaluate overall and five-year conditional survival of consecutive patients operated for the treatment of CRLM at the Liver Surgery Unit – Hospital das Clinicas – University of Sao Paulo after the institution of a specialized multidisciplinary cancer center. Methods: Retrospective analysis comparing two institutional periods in the management of CRLM. Consecutive patients undergoing liver resection with curative intent and histologically confirmed diagnosis of MHCR, between January 2000 and December 2015 (follow up until December 2018). ERA 1 corresponded to the initial experience (January 2000 through February 2009) and ERA 2 (March 2009 to December 2015) corresponded to the period after the adoption of specialized oncologic multidisciplinary care. Demographic profile, oncological data, operative outcomes and survival analysis were performed, including 5-year conditional survival. Results: 383 patients were submitted to 402 hepatectomies, 98 patients were operated during ERA 1 and 285 during ERA 2. During ERA 1 patients presented higher levels of CEA (177.0 ng/dL vs. 70.3 ng/dL p<0.001), greater mean size of the largest resected tumor (47.5 mm vs. 33.9 mm p<0.001). In ERA 2 there were more synchronous (70.0% vs. 58.5% p=0.041), bilobar (22.3% vs. 34.8% p=0.025) and multinodular CRLM (22.8% vs. 11.5% p=0.031). During ERA2 exposure to preoperative chemotherapy was more frequent (77.3% vs. 34.1% p<0.001), predominantly oxaliplatin based. Operative results indicated that ERA 2 employed mostly minor (65.9% vs. 42.6% p<0.001) and non-anatomical resections (40.7% vs.12.8% p<0.001). Operative complications (ERA 1 32.3% vs. ERA 2 36.3% p=0.481) and overall mortality were similar between studied periods. Surgical margins did not vary significantly between ERAS. Median follow up was 42.0 months for the whole cohort (ERA1 35.5 months; ERA2 43.0 months). Overall survival in 5 years was 34.5% for ERA 1 and 48.0% for ERA 2 (p=0.011). During follow up years 1 to 5, 5-year conditional survival varied from 35.0% to 62.0% in ERA 1 and from 45.9% to 63.6% in ERA 2. being greater in every follow up year in ERA 2. Conclusion: The changes along time in the multidisciplinary specialized care to CRLM resulted in increased overall and conditional survival in ERA 2.

Hepatitis C and IL-6 with 174G/C Gene Polymorphism in β-Thalassemia

Polymorphisms have been shown to affect the progression of disease in patients with Iraqi thalassemia in the 174 G\C area of IL-6. The objective of this research was, therefore, to determine the connection of IL-6 gene polymorphisms and thalassemia severity in Iraqi patients. Case-control research of 60 patients diagnosed with β-TM at the thalassemia center in AL-Zahra hospital in AL-Najaf City, Iraq, with a group of 40 healthy patients, was used as control; the patients (26 males and 34 females) were 3–49 years of era. Blood samples were gathered and controlled from all patients. Blood used to extract DNA to detect IL-6 G\C polymorphism using SSP-PCR. The outcome showed that the male age range (56.6%) was higher than the woman (42.6%), and the age range (10-19) was higher than the other. The outcome shows that GG genotype and G allele in thalassemia patients are a risk factor of severity, whereas CC genotype and C allele are a protective factor of severity. Conclusion: The polymorphism in IL-6 at a place (174 G\C) is associated with thalassemia pathogenesis in the GG genotype and IL-6 considers the seriousness of thalassemia as a predictive factor. How to cite this article: Alsadawi, A.A., Jaleel duabel, A.K.A. and Alnaji, H.A. (2019). Hepatitis C and IL-6 with 174G/C Gene Polymorphism in β-Thalassemia. International Journal of Drug Delivery Technology, 9(4): 617-622.. Source of support: Nil. Conflict of interest: None.

RAIYMBEK BATYR – A HISTORICAL FIGURE

The article discusses the exploits of Raimbek Batyr, who completed the liberation struggle in the eastern region of the Zhetysu region in the last years of era of the «Aktaban Shubyryndy, Alkakol Sulama». Raiymbek is a hero who is supreme in the interests of the tribe who have fought all their lives for the general Kazakh liberation. His battle is to liberate his land and his people, who were suffering from the Kalmyks. This article also discusses the sources of K. Sauranbayev about the grandfather of the warrior Hangeldi, his loyal companions: Bakai Batyr, Aralbai Batyr, Kopai Batyr, Satay Batyr, Iryseldi Batyr.

First 1500 Kidney Transplants at the Institute of Nephrology and Urology in Uruguay: Analysis of the Results

BackgroundThe Institute of Nephrology and Urology (INU) has performed 75% of kidney transplantations (KT) in Uruguay during its 35 years of activity, with 90.6% from cadaveric donors. We investigated the risk factors (RF) for delayed graft function (DGF) and patient and graft survival (SV). MethodsWe analyzed retrospectively the characteristics and evolution of 1500 KT performed by INU until December 2014. The incidence of DGF and RF for patient and graft SV were analyzed in 4 eras, according to the year that KT was performed. ResultsThe number of KT per year has progressively increased until reaching 40 KT per million population in 2006, with a decrease of the living donor KT (LDKT) rate. The age of the donors (D) and recipients (R) as well as the time on dialysis (TOD) have progressively increased over the different eras. Five hundred twenty-five R (35%) presented with DGF. The RF for DGF were the age of the R and the D, the TOD, the DDKT, and the warm ischemia time (WIT). In the DDKT group, the cold ischemia time and “died of stroke” were added factors. The death-censored graft SV at 1, 5, 10, and 15 years were 90%, 76%, 62%, and 49%, respectively. They improved as from era I, the patient SV being 92%, 83%, and 75% at 1, 5, and 10 years, in era I; 98%, 93%, and 86% in era II; 98%, 92%, and 83% in era III; and 95% and 90% at 1 and 5 years in era IV (P < .001). The graft SV over the same periods was 76%, 58%, and 40% in era I; 88%, 68%, and 52% in era II; 93%, 81%, and 70% in era III; and 93% and 85% at 1 and 5 years in era IV (P < .0001). The RF for patient SV were diabetes mellitus, era I, lower albuminemia, older age or TOD, and DGF. For kidney SV, the era, the age of the R, TOD, DGF, and D older than 60 years were RF associated with a worse evolution. In DDKT, the RF for the graft SV were the era, younger age of the R, and DGF. The group with the worst graft SV was the one made up of children and adolescents. ConclusionsOur results relating to patient and graft SV are acceptable and comparable to those mentioned on large records such as the OPNT/SRTR and the Collaborative Transplant Study. This has been the case, even though we have transplanted increasingly aged patients, with increasingly aged donors, or donors with associated pathology. The risk factors that we found both for DGF and SV have also been pointed out by other authors. The validity of some findings has the limitation of being from a retrospective analysis; hence, they should be corroborated by a prospective study.

Volume-staged radiosurgery for large arteriovenous malformations: an evolving paradigm.

OBJECT Large arteriovenous malformations (AVMs) remain difficult to treat, and ideal treatment parameters for volume-staged stereotactic radiosurgery (VS-SRS) are still unknown. The object of this study was to compare VS-SRS treatment outcomes for AVMs larger than 10 ml during 2 eras; Era 1 was 1992-March 2004, and Era 2 was May 2004-2008. In Era 2 the authors prospectively decreased the AVM treatment volume, increased the radiation dose per stage, and shortened the interval between stages. METHODS All cases of VS-SRS treatment for AVM performed at a single institution were retrospectively reviewed. RESULTS Of 69 patients intended for VS-SRS, 63 completed all stages. The median patient age at the first stage of VS-SRS was 34 years (range 9-68 years). The median modified radiosurgery-based AVM score (mRBAS), total AVM volume, and volume per stage in Era 1 versus Era 2 were 3.6 versus 2.7, 27.3 ml versus 18.9 ml, and 15.0 ml versus 6.8 ml, respectively. The median radiation dose per stage was 15.5 Gy in Era 1 and 17.0 Gy in Era 2, and the median clinical follow-up period in living patients was 8.6 years in Era 1 and 4.8 years in Era 2. All outcomes were measured from the first stage of VS-SRS. Near or complete obliteration was more common in Era 2 (log-rank test, p = 0.0003), with 3- and 5-year probabilities of 5% and 21%, respectively, in Era 1 compared with 24% and 68% in Era 2. Radiosurgical dose, AVM volume per stage, total AVM volume, era, compact nidus, Spetzler-Martin grade, and mRBAS were significantly associated with near or complete obliteration on univariate analysis. Dose was a strong predictor of response (Cox proportional hazards, p < 0.001, HR 6.99), with 3- and 5-year probabilities of near or complete obliteration of 5% and 16%, respectively, at a dose < 17 Gy versus 23% and 74% at a dose ≥ 17 Gy. Dose per stage, compact nidus, and total AVM volume remained significant predictors of near or complete obliteration on multivariate analysis. Seventeen patients (25%) had salvage surgery, SRS, and/or embolization. Allowing for salvage therapy, the probability of cure was more common in Era 2 (log-rank test, p = 0.0007) with 5-year probabilities of 0% in Era 1 versus 41% in Era 2. The strong trend toward improved cure in Era 2 persisted on multivariate analysis even when considering mRBAS (Cox proportional hazards, p = 0.055, HR 4.01, 95% CI 0.97-16.59). The complication rate was 29% in Era 1 compared with 13% in Era 2 (Cox proportional hazards, not significant). CONCLUSIONS VS-SRS is an option to obliterate or downsize large AVMs. Decreasing the AVM treatment volume per stage to ≤ 8 ml with this technique allowed a higher dose per fraction and decreased time to response, as well as improved rates of near obliteration and cure without increasing complications. Reducing the volume of these very large lesions can facilitate a surgical approach for cure.

Pediatric Invasive Haemophilus influenzae Infections in Israel in the Era of Haemophilus influenzae Type b Vaccine

The conjugated Haemophilus influenzae (Hi) type b vaccine caused a marked decrease in invasive Hi disease rates. Nonencapsulated Hi infection now constitutes most invasive Hi morbidity and mortality. This study examines invasive Hi infection incidence in Israel in the postvaccine era years, 2003-2012, and characterizes the epidemiology, clinical diagnosis and case fatality rates of invasive Hi disease in children <15 years of age. An ongoing, nationwide prospective surveillance program for invasive Hi infections in Israel. Epidemiologic and clinical data were collected. Diagnoses were classified as meningitis, pneumonia, bacteremia/sepsis and other clinical foci. Overall, 389 cases of invasive Hi infections were identified; 242 (62%) nontypable Hi (NTHi), 103 (26%) Hi type b (Hib) and 41 (11%) encapsulated non-b Hi (enbHi). Children <1 year of age accounted for 51% of the overall disease. Invasive Hi disease incidence in children <15 years of age was stable with a mean annual incidence (per 100,000) of 2.0 ± 0.4. The highest incidence of invasive Hi infections was among infants <1 year with rates of 6.2, 4.9, 1.6 and 12.7 for NTHi, Hib, enbHi and total Hi, respectively. The clinical diagnoses of NTHi and enbHi were similar, but differed from Hib with the former presenting mostly as isolated sepsis/bacteremia and the latter primarily as meningitis. Among children with invasive Hib infection, 40% were classified as vaccine failure. In the post-Hib vaccination era, invasive Hi morbidity and mortality are largely attributed to NTHi sepsis. Still, with the changing epidemiology of invasive Hi, continued surveillance of all Hi strains is justified.

Improvements in observed and relative survival in follicular grade 1-2 lymphoma during 4 decades: the Stanford University experience

AbstractRecent studies report an improvement in overall survival (OS) of patients with follicular lymphoma (FL). Previously untreated patients with grade 1 to 2 FL treated at Stanford University from 1960-2003 were identified. Four eras were considered: era 1, pre-anthracycline (1960-1975, n = 180); era 2, anthracycline (1976-1986, n = 426); era 3, aggressive chemotherapy/purine analogs (1987-1996, n = 471); and era 4, rituximab (1997-2003, n = 257). Clinical characteristics, patterns of care, and survival were assessed. Observed OS was compared with the expected OS calculated from Berkeley Mortality Database life tables derived from population matched by gender and age at the time of diagnosis. The median OS was 13.6 years. Age, gender, and stage did not differ across the eras. Although primary treatment varied, event-free survival after the first treatment did not differ between eras (P = .17). Median OS improved from 11 years in eras 1 and 2 to 18.4 years in era 3 and has not yet been reached for era 4 (P < .001), with no suggestion of a plateau in any era. These improvements in OS exceeded improvements in survival in the general population during the same period. Several factors, including better supportive care and effective therapies for relapsed disease, are likely responsible for this improvement.

Preface: twenty years of ERA

It gives me great pleasure to be able to congratulate ERA on its 20th anniversary. At home I have a daughter who is twenty, and she is lovely. In ERA, I have another close friend at the age of twenty, and this, too is a most admirable friend. ERA is, first of all, an academy, but without being academic. ERA is an institution for training, for exchange of experience and ideas, and a forum for debate and interaction. ERA draws on the expertise of legal professionals from many different fields and functions—including people from academia but not limited to them—and it brings together audiences from a variety of legal professions, in order to develop and enrich their knowledge and competencies. ERA is characterised by multi-professionalism in its field of activity, and this is one of its major assets. Secondly, ERA is a European academy. It is today truly cross-European, not just in terms of the reach of its activities in the various Member States, but also in terms of its ability to engage experts and high-level representatives from the European institutions to bring their contributions to the activities and events in the programme. This combination of multiculturalism, multi-professionalism and “multi-levelism” in ERA’s activity is, together with the quality of the programmes, the essence of its contribution to European legal training and debate. The value added is, I think, beyond doubt at this point in ERA’s still relatively short but quite impressive history. Thirdly, and essentially of course, ERA is an academy of law, European law. As we all know, European Union law has evolved into a special kind of legal order,

The obstetrician and the extremely immature fetus (24-26 weeks): outcome to 5 years of age.

The aims of this study were to determine the outcome to 5 years of age for fetuses 24-26 weeks of gestational age from the obstetric viewpoint, and to determine if their outcome has improved over time. Consecutive fetuses with gestational ages from 24-26 weeks born at the Royal Women's Hospital, Melbourne, during 2 separate eras, Era 1 (1977-1982; n = 198) and Era 2 (1985-1987; n = 128) were studied and their outcome to 5 years of age determined. Fetuses referred with lethal malformations or clearly dead before the onset of labour were excluded. The stillbirth rates were similar in both eras (Era 1 23.7%, Era 2 21.9%), but the proportion of survivors to 5 years of age was much higher in Era 2 (Era 1 19.7%, Era 2 30.5%, X2 = 5.0, p < 0.03; odds ratio 1.80; 95% confidence interval [CI] 1.07 to 3.04). Overall, both the proportion and the absolute number of severely disabled children fell over time; 4 children survived with severe sensorineural disability in the 5 1/4 years of Era 1, but only one child in the 3 years of Era 2. From the obstetric viewpoint, only 1.5% of total births survived with a severe sensorineural disability, no higher than the rate expected for children born at term. Fetuses born at 24-26 weeks of gestational age need not contribute disproportionately to the number of severely disabled children in the community; furthermore, their outcome is improving over time. From the obstetrician's viewpoint, survival chances rather than sensorineural outcome should dominate decision-making at these extremely preterm gestations.