623 e-Letters

  • Re: Haemoglobin discordances in twins: is "really" due to differences in timing of cord clamping? A consideration to Verbeek L and co-authors

    We thank Dr. de Carolis and co-authors for their interest in our study on hemoglobin (Hb) level differences at birth in uncomplicated monochorionic and dichorionic twins. We found that second-born monochorionic and dichorionic twins have higher Hb levels at birth compared to first-born twins when delivered vaginally. Since Hb differences at birth are also present in dichorionic twins, we hypothesized that Hb differences might be due to differences in timing of cord clamping, rather than placental vascular anastomoses.

    Several studies demonstrated that delayed cord clamping is associated with higher Hb levels at birth compared to early cord clamping[1], the physiological mechanism is not well understood. Although we agree that other factors may influence Hb levels during delayed cord clamping at birth, the effect of uterine contractions may be not as clear-cut as dr. de Carolis and co-authors suggest. It has been suggested that uterine contractions influence placento-fetal transfusion. However, Westgate et al. found that uterine contractions primarily cause a pressure-induced, differential reduction in flow in both vessels as well as a reduction in uterine flow.[2] This was also observed in lambs, where oxytocin-induced contractions led to a cessation of the umbilical venous flow and the flow in the umbilical artery was greatly reduced resulting in retrograde flow during diastole.[3]

    Reference List

    1. McDonald SJ, Middleton P, Dowswell T, Morris PS: Eff...

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  • Implementation of an automated oxygen Control system- Are we ready?

    We read with great interest the article by Van Zanten HA et al., published in this journal and found the results impressive.[1] However, we have certain observations about the conduct of the study
    Even though the authors state that this report was part of a quality improvement initiative in their NICU, the authors have neither reported the results in the format suitable for a quality improvement study nor have clearly stated the design; at the end of introduction they seem to mention that this was a retrospective data analysis; whereas, in the first line of the methods they state the design as a prospective observational study. Even though the automatic oxygen controller group would not have been affected much by any one of the design, the impact would have been in the manual group, keeping especially the training of the NICU staff in mind. It’s also worth emphasizing here that the authors mention about the local guidelines practiced for manual titration of supplemental oxygen based on the saturations, for the sake of external validity.[2]
    Minute wise data points used in this study may have significantly underestimated the hypoxemic episodes and thereby the proportion of times an infant remained in the ‘below target range’ saturations. In a logical sense, manual titration would have happened sooner than expected for a hypoxemic event and hence would not have been captured if more frequent data points are not considered. Using the same technology and a lesser in...

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  • congenital depression of skull

    I read with interest your article on spontaneous ping pong parietal fracture in newborns with impressive color images .The word 'fracture' can be quite traumatic to the parents and should avaoided if there is no radiological evidence of break in the cortex 1. It should then just be labelled as depression of skull bone without a fracture rather than labelling as DCF( depressed calvarial fracture) as mentioned in your article .You have also clearly demonstrated in your 3D CT image also that there was no break but only invagination of parietal bone .The management would also not change whether the depression is with or without fracture .
    References -
    Tayeh,et al.BMJCase Rep2016.doi:1136/bcr-2016-215437

  • Implementation of an automated oxygen Control system- Are we ready?

    We read with great interest the article by Van Zanten HA et al., published in this journal and found it very useful.1 The author rightly stated that the results reflect the real situation as data were collected for the duration infants were admitted, while nurses taking care of them and where workload varied. It will be very relevant for developing countries where nurse patient ratio is poor. But; at the same time would like to offer following comments, clarification to which would benefit the readers of this journal and will help in replication of these results in different settings also.
    It is not very clear whether it was a prospective study or retrospective. In Introduction section, in the end, the author mentioned that we performed a retrospective study in preterm infants to evaluate automated fraction of inspired oxygen (FiO2) control when it was used as standard care and thus for a longer period. While in “Methods” section it is mentioned that it was a prospective observational study. These contradictory statements create confusion to the reader.
    The author mentioned that during the manual period, the nurses manually titrated the supplemental oxygen following local guidelines. However; these guidelines are not given in the current paper. It would be better if clear guidelines would have been described like other studies to improve the external validity and generalizability.2
    In the present study, FiO2 and pulse oximeter saturation (SpO2) were sa...

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  • Haemoglobin discordances in twins: is "really" due to differences in timing of cord clamping? A consideration to Verbeek L and co-authors
    Maria Pia De Carolis

    Dear Editor, We read with interest the article by Verbeek L. et al [1], showing that the second-born twin has higher levels of hemoglobin (Hb) than first-born co-twins after vaginal delivery (VD; Hb differential effect does not occur in twins delivered by Caesarean section. Since Hb difference is present in both uncomplicated monochorionic (MC) and dichorionic (DC) twin pairs, authors focused on the time difference of umbi...

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  • Logistic regression equation and (co)variance matrix for estimating developmental outcome in very preterm infants
    Pieter L. Degraeuwe

    Neonatal health-care providers have the duty to fully inform parents about the prognosis of their sick, extremely preterm infant. Prognostication is however difficult since survival and long-term outcome are multifactorially influenced, and the quality of prognosis research is often poor. [1] By reporting "Determinants of developmental outcomes in a very preterm Canadian cohort" [2], Synnes et al. extend the previous wor...

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  • Congenital intraoral Fordyce spots misdiagnosis
    Thamer M. Musbah

    Dear editor, We read with interest the report by Arun Babu and colleagues1 and have concern with the diagnosis of "congenital intraoral Fordyce spots" that was rendered in this case. Fordyce spots/granules in the oral cavity are considered ectopic holocrine glands, and they differ considerably from those shown in the mentioned article. Fordyce spots usually appear as asymptomatic, multiple yellowish raised papules with...

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  • Re: Neonatal antibiotics; a response to White and co-authors
    Alice E. White

    We appreciate the comments regarding our manuscript on the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado. With regards to the writer's observation about the likelihood of underestimating the primary outcome, we acknowledge that underreporting is an issue in the Colorado birth certificate database, as with most large administrative datasets. As stated in the manuscript: "Incidence...

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  • Current UK practice: Infant Car Seat Challenges
    Rebecca C H Towler

    This paper highlights some limitations in the use of infant car-seat challenges (ICSCs) to monitor for abnormal cardiorespiratory events prior to hospital discharge[1]. Current practice is non-standardised and unlikely to replicate actual infant experience.

    In the USA it is recommended that all infants born <37 weeks gestation or birth-weight <2500g should have a period of observation in a car-seat prior t...

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  • Response to the article by Zanardo et al
    Stefano Ghirardello

    We read with interest the article by Zanardo et al (1). The authors found a lower pre-ductal SpO2, a higher hearth rate (HR) and hematocrit in term infants born by cesarean delivery (CD) compared to those born by vaginal delivery (VD), similarly to the findings by Dawson et al (2) but not confirmed by others (3). The authors did not mentioned if a different management of cord clamping was performed between vaginal and ce...

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