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I read with great interest the commentary by John D. Lantos on the
SUPPORT study controversy. Dr. Lantos makes a compelling argument that the
OHRP was misguided in its criticism of SUPPORT, primarily because both
arms of the trial were within standard of care.1-2
Eligible infants whose parents refused to participate in SUPPORT
received the same medical care, but instead of randomization via protocol,
they were su...
I read with great interest the commentary by John D. Lantos on the
SUPPORT study controversy. Dr. Lantos makes a compelling argument that the
OHRP was misguided in its criticism of SUPPORT, primarily because both
arms of the trial were within standard of care.1-2
Eligible infants whose parents refused to participate in SUPPORT
received the same medical care, but instead of randomization via protocol,
they were subject to "idiosyncratic clinical judgments in the absence of
good evidence."1 That is a frightening concept. How can it be easier for a
physician to change clinical practice on a whim than it is for her to
study those very same differences in practice using the scientific method?
I agree that the informed consent process needs to change, but I
propose that we change the entire system. If both intervention arms of a
clinical trial are within standard practice, the IRB should not require
written informed consent at all. "In such situations," according to Dr.
Lantos, "there may be no incremental risk to being in a study. There may
even be some benefit." 1 Of course, these studies would continue to
require verbal assent from parents and prior approval from the IRB, but
shifting to an opt-out rather than an opt-in regime would significantly
benefit the progress of medicine. Indeed, some institutions outside of the
United States have already adopted this policy.3
No one wants to get rid of oversight for clinical research entirely,
but too much oversight has had a measurable and significant chilling
effect on scientific advancement.4 In my opinion, there is no doubt that
the obstacles to initiating and conducting clinical research would be more
navigable without the burden of universal written informed consent.
REFERENCES 1. Landtos JD. Learning the right lessons from the SUPPORT
study controversy. Arch Dis Child Fetal Neonatal Ed. 2013;epub ahead of
print. 2. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal
Research Network. Target ranges of oxygen saturation in extremey preterm
infants. N Engl J Med. 2010;362:1959-1969. 3. Reignier J, Mercier E, Le
Gouge A, et al. Effect of not monitoring residual gastric volume on risk
of ventilator-associated pneumonia in adults receiving mechanical
ventilation and early enteral feeding: a randomized controlled trial.
JAMA. 2013;309:249-56 4. O'Herrin JK, Kudsk K, Frost N. Health insurance
portability Accountability Act (HIPAA) regulations: effect on medical
record research. Ann Surg. 2004;239:772-776.
I enjoyed reading this paper, but I have some comments about the
statistics, which I think should have been picked up in the peer review
process.
In the paper it is stated that the Bland Altman plot showed good
correlation. Correlation should produce a coefficient and a p-value.
The paper does not report the value for the mean difference between
the two methods. From the graph it looks about -0.01 mmol/L. The limits of
agreement look to be about 0.49 mmol/L to -0.49 mmol/L.
I estimate the standard deviation of the differences to be around
0.25 mmol/L, making the standard error of the mean about 0.02 mmol/L. Thus
there is no systematic difference between the two methods as the 95%
confidence intervals for the mean difference are approximately 0.03 mmol/L
to -0.05 mmol/L, crossing zero.
If you want to replace one measure with another you must demonstrate
that there is no a systematic difference. While it is implicit in the
figures and text it is not stated.
More importantly 95% of the differences are within 0.5 mmol/L.
However, once the glucose value in the baby is only 2 to 2.5 this has
massive clinical importance.
I think there are 2 ways of addressing this issue. First whatever your
unit's lower limit of glucose acceptability is you must add the limits of
agreements to that (0.5 mmol/L in this case). However, would it be better,
given the consequences of prolonged hypoglycaemia, to calculate the 99%
confidence interval, or even higher and add that to your usual lower
limit. If enough samples were collected it is possible to calculate a
minimum acceptable value for the new test.
There is another method to address the accuracy of the new
instrument, although seemingly constant, but possibly significantly
clinically less reliable at lower glucose readings. We note that the
spread of difference is reasonably constant over the range of
measurements, as suggested in the graph. However, at 8 mmol/L the limits
of agreement of 0.5 mmol/L represent a margin of error of around 6%, but
at 2 mmol/L it is 25%. I have seen studies re-plot the Bland Altman graph
with the differences as a percentage of the mean value. In this case it
would emphasise how at clinically important low values, an in house
guideline must be in place to ensure that hypoglycaemia is not
undiagnosed.
It is my firm belief that these issues should have been picked up in
the peer review. The authors could have then have shown the data I have
estimated and concluded that their validation is useful for their unit,
but your unit would need to do its own testing before adopting this new
method of measuring glucose in preterm arterial samples.
We read with interest the thought provoking paper written by Dr.
Bodeau-Livinecr and colleagues on behalf of the EPIPAGE. They concluded
that compared with very preterm singletons, twins had higher mortality, no
difference in severe deficiencies, but slightly lower Mental Processing
Composite scores at 5 years. 1
The Authors suggest that although all the infants studied who were
born preterm had been exposed...
We read with interest the thought provoking paper written by Dr.
Bodeau-Livinecr and colleagues on behalf of the EPIPAGE. They concluded
that compared with very preterm singletons, twins had higher mortality, no
difference in severe deficiencies, but slightly lower Mental Processing
Composite scores at 5 years. 1
The Authors suggest that although all the infants studied who were
born preterm had been exposed to a pregnancy complication that had led to
their early birth, these may not be the same (i.e. in utero death of the
co-twin, being born second, monochorionic placenta, and birthweight
discordance) and may not have the same neurodevelopmental consequences in
singletons and twins. 1
Accumulating evidence indicates that the prenatal environment plays a
significant role in shaping children's neurodevelopment. Some authors
hypothesize that prenatal psychological distress on the part of the mother
is a risk factor for children's neurocognitive development. 2 We have been
assessing subjective states in singleton and twin pregnant women using
L?scher's 8-color test. 3 According to test results, singleton and twin
pregnant women share feelings denoting a particular emotional state,
idealizing their status, although perceiving it as stressful. Twin
pregnant women are afraid of building a relationship with their infants
and those women who became pregnant with twins following assisted
reproduction technologies perceive their pregnancy as exhausting,
characterized by a deep-seated anxious state and by the wish to give
birth soon. This is a particularly complex situation in which mothers are
at risk for anxiety, depression, and unsatisfactory postnatal bonding.
Studies specifically including maternal psychological distress in
their design will be able to assess the relative and/or synergistic impact
of these prenatal experiences on developmental trajectories. Once again,
we would like to thank the Authors for bringing these considerations to
the forefront and hope to read other articles on this timely subject.
References
1. Bodeau-Livinec F, Zeitlin J, et al. Do very preterm twins and
singletons differ in their neurodevelopment at 5 years of age? Arch Dis
Child Fetal Neonatal Ed. 2013 Jul 17.
The authors are to be thanked for looking into outcomes of fetuses
identified with Critical Congenital Heart Disease (CCHD) based on the
location of birth. Bennett et al (1) came to the same conclusion: that
birth hospital had little impact on survival. As the authors point out,
75% of CCHD may be missed during prenatal evaluations. This means that the
physicians at the non-specialty hospitals have to be able to recognize...
The authors are to be thanked for looking into outcomes of fetuses
identified with Critical Congenital Heart Disease (CCHD) based on the
location of birth. Bennett et al (1) came to the same conclusion: that
birth hospital had little impact on survival. As the authors point out,
75% of CCHD may be missed during prenatal evaluations. This means that the
physicians at the non-specialty hospitals have to be able to recognize and
stabilize these critically ill babies. Based on the data from Anagnostou
et al and Bennett, I argue that it is better to deliver these babies
wherever the mother wants and provide local support as necessary. These
episodes of planned care will help the local staff remain competent to
care for the majority of patients with CCHD who will arrive unexpectedly.
(1) Influence of Birth Hospital on Outcomes of Ductal-Dependent
Cardiac Lesions Tellen D. Bennett, Matthew B. Klein, Mathew D. Sorensen,
Anneclaire J. De Roos
and Frederick P. Rivara DOI: 10.1542/peds.2009-2829
; originally published online November 22, 2010; 2010;126;1156 Pediatrics
Dear Editor,
The paper by Zareen et al. recently published in Archives, evaluates the
effectiveness for suctioning meconium of various catheters and bulb
syringes. The data provide useful information for caregivers of infants in
the delivery room. [1]
The authors describe meconium suctioning as a routine procedure. They
quote: "However, recent guidelines recommend that, if the baby born with
meconium stained fluid has a n...
Dear Editor,
The paper by Zareen et al. recently published in Archives, evaluates the
effectiveness for suctioning meconium of various catheters and bulb
syringes. The data provide useful information for caregivers of infants in
the delivery room. [1]
The authors describe meconium suctioning as a routine procedure. They
quote: "However, recent guidelines recommend that, if the baby born with
meconium stained fluid has a normal respiratory effort, normal muscle tone
and a heart rate greater than 100 bpm, one should simply use a bulb
syringe (BS) or large bore catheter to clear secretions and any meconium
from the mouth and nose as needed". They further comment: "There is still
some debate regarding whether or not suctioning in this setting confers
any benefit to the infant, who does not require intubation". [1] The
Neonatal Resuscitation Program of the AAP and ILCOR do not recommend any
longer routine suction of meconium stained infants. Suction should be
neither performed with clear nor with meconium stained amniotic fluid
(MSAF) if the infant is vigorous, has normal respiratory effort, normal
muscle tone and a heart rate greater than 100 bpm. The guidelines
emphatically recommend that, with clear or MSAF, suction should be
exclusively performed if the infant's airway appears evidently obstructed
by secretions or, in infants with MSAF who are not breathing, just before
intubation The authors should have referred to the latest recommendations.
[2, 3]
ILCOR and other institutions base their guidelines in serious scientific
evidence, directed toward improving clinical practice. For many years,
literature search failed to yield randomized controlled trials addressing
topics related to therapies used during the birth process.
Fortunately in the last decade, several studies performed in the delivery
room followed appropriate evidence based medicine design allowing for
rational changes to which all clinicians should progressively adapt. [4,
5]
Adriana M. Aguilar
Nestor E. Vain
FUNDASAMIN (Fundaci?n para la Salud Materno Infantil)
Honduras 4160, Buenos Aires, Argentina (1180)
Tel/ Fax 54-11-4863-4102
Correspondence to:
Nestor E. Vain
E- Mail address: nvain@fundasamin.org.ar
References:
1. Zareen, Z., C.P. Hawkes, E.R. Krickan, E.M. Dempsey, and C.A.
Ryan, In vitro comparison of neonatal suction catheters using simulated
'pea soup' meconium. Arch Dis Child Fetal Neonatal Ed, 2013. 98(3): p.
F241-3.
2. Kattwinkel, J., Textbook of Neonatal Resuscitation. 6th edition. 6 ed.
Vol. 1. 2011: American Academy of Pediatrics and American Heart
Association.
3. Perlman, J.M., J. Wyllie, J. Kattwinkel, D.L. Atkins, L. Chameides,
J.P. Goldsmith, et al., Part 11: Neonatal Resuscitation: 2010
International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment Recommendations. Circulation,
2010. 122(16 Suppl 2): p. S516-38.
4. Vain, N.E., E.G. Szyld, L.M. Prudent, T.E. Wiswell, A.M. Aguilar, and
N.I. Vivas, Oropharyngeal and nasopharyngeal suctioning of meconium-
stained neonates before delivery of their shoulders: multicentre,
randomised controlled trial. Lancet, 2004. 364(9434): p. 597-602.
5. Saugstad, O.D., S. Ramji, R.F. Soll, and M. Vento, Resuscitation of
newborn infants with 21% or 100% oxygen: an updated systematic review and
meta-analysis. Neonatology, 2008. 94(3): p. 176-82.
Dear Editor,
Thank you for the opportunity of answering to the comments of Chiesa (1)
about our paper (2). First, the assay: Procalcitonin (PCT) was measured
with an immunoluminometric, quantitative method, as in studies cited by us
and by Chiesa. We used reagents Brahms and Berthold LB9507 luminometer
(Dasit). The analytical signal, proportional to the concentration of the
PCT in the sample, was converted into continuou...
Dear Editor,
Thank you for the opportunity of answering to the comments of Chiesa (1)
about our paper (2). First, the assay: Procalcitonin (PCT) was measured
with an immunoluminometric, quantitative method, as in studies cited by us
and by Chiesa. We used reagents Brahms and Berthold LB9507 luminometer
(Dasit). The analytical signal, proportional to the concentration of the
PCT in the sample, was converted into continuous concentration values. The
definitive results were available in 5-6 hours from the blood collection,
that we considered as "fast".
Second: the first blood sample was taken on admission of all patients
to NICU (time 0), in the absence of clinical and laboratory signs of
infection, to check the increase of PCT during the subsequent infection,
when it would be manifested. These results were never included in the
calculation of the maximum value of PCT during infection. Infants with
maternal-fetal infections were excluded from the study. In neonates who
developed signs of nosocomial sepsis at least 48 h after the admission in
NICU, PCT levels were further measured, as stated in the methods, at least
within 24 and 48 h after the onset of the infection. These data only were
used to calculate the median value of the highest PCT levels during the
infection.
PCT was also measured in 762 (GA 34+/-4 weeks, BW 2130+/-863 g) critically
ill, but uninfected, patients; 205 of them were VLBW (29+/-3 weeks, BW
1123+/-258g), admitted to NICU in the first three days of life. Our
unpublished data confirm a physiologic increase in PCT levels during the
first days of life (3-5). Considering all uninfected neonates, the median
values of PCT by day of life were: 0.40 ng/ml (IQR 0.21-1.20), in the
first , 2.38 ng/ml (IQR 0.77-8.76), in the second and 0.52 ng/ml (IQR 0.28
-1.37), in the third. We obtained similar results in VLBW infants.
Stratifying for BW (collinear with gestational and postnatal age), the
accuracy of PCT did not differ significantly in neonates with a BW 1500-
2500 gr from that of heavier BW: a cut-off of 2.4 ng/ml. yielded a
sensitivity of 55%, a specificity of 84% and a positive Likelihood Ratio
of 3.4. Finally, in the first study of Chiesa, cited in his letter, (3)
PCT was measured in healthy neonates, and a nomogram was established with
statistical cut-offs. Despite this, when the problem of late-onset sepsis
was investigated, a matched case-control design was adopted. (4) In this
study cases and controls were defined, on clinical grounds, as we did,
apparently ignoring statistical cut-offs and postnatal age, that was one
of the variables of matching. Turner introduced as well a nomogram by
gestational age in the first 4 days of life (5). However he has published
results about PCT accuracy in another study (6), with the current,
evidence-based approach, where different cut-offs were explored to
establish the most appropriate for clinical application in a given
context,. A number of biological or clinical reasons (e.g. concomitant
diseases, age, labour, drugs etc.) can lead to misdiagnosis, measured by
sensitivity, specificity and the other values of accuracy, that we hold as
meaningful with our approach.
Dr.ssa Cinzia Auriti
Dr. Vincenzo M. Di Ciommo
1). Chiesa C, Pacifico L, Osborn JF, Natale F, De Curtis M
Procalcitonin for early diagnosis of neonatal nosocomial sepsis Arch Dis
Child Fetal Neaonatal Ed Published 31 March 2011
2). Auriti C, Fiscarelli E, Ronchetti MP, at al. Procalcitonin in
detecting neoanatal nosocomial sepsis. Arch Dis Child Fetal Neaonatal Ed
2011.Published online First: 15 March 2011 doi:10.1136/adc.2010.194100
3) Chiesa C, Panero A, Rossi N, et al. Reliability of procalcitonin
concentrations for the diagnosis of sepsis in critically ill neonates.
Clin Infect Dis 1998;26:664-72.
4) Chiesa C, Natale F, Pascone R, et al. C reactive protein and
procalcitonin: Reference intervals for preterm and term newborns during
the early neonatal period. Clin Chim Acta 2011; 412: 1053-59
5) Turner D, Hammerman C, Rudensky B, et al. Procalcitonin in preterm
infants during the first few days of life: introducing an age related
nomogram. Arch Dis Child Fetal Neonatal Ed 2006;91:F283-6
6) Turner D, Hammerman C, Rudensky B, et al. The role of procalcitonin as
a predictor of nosocomial sepsis in preterm infants. Acta Paediatr
2006;95:1571-6
We read with great interest the review "Patent ductus arteriosus-time
to grasp the nettle" (Smith, Kissack, ADC F&N 2013; 98) which highlighted
the controversies in PDA management and variation in management. Evidence
to support the routine closure of the ductus arteriosus to improve
neonatal morbidity remains inconclusive1. We recently conducted a survey
on PDA management in neonatal units across England to understan...
We read with great interest the review "Patent ductus arteriosus-time
to grasp the nettle" (Smith, Kissack, ADC F&N 2013; 98) which highlighted
the controversies in PDA management and variation in management. Evidence
to support the routine closure of the ductus arteriosus to improve
neonatal morbidity remains inconclusive1. We recently conducted a survey
on PDA management in neonatal units across England to understand current
clinical practice.
A structured questionnaire was emailed with an online hyperlink to
consultant neonatologists working in tertiary neonatal units in
England.Fourteen questions addressed work load, management strategies,
fluid management, drugs used, threshold for treatment of PDA, cardiology
service available in their unit. The survey was conducted from August 2012
to November 2012.
The response rate was 75%.The majority (68%) of neonatologists felt that a
symptomatic strategy best describes their practice for treating PDA, while
25% felt that they practised a presymptomatic/ echo directed targeted
strategy. Only two neonatologists (at the same unit) practice a
prophylactic treatment strategy and two neonatologists felt that their
practice does not fit in any of above categories. Significant variation
was observed when percentage of preterm babies treated for PDA/year was
compared within different units practising same symptomatic strategy (7%
to 75%).The drug of choice for treating PDA was ibuprofen for 74% of
neonatologists, with only 26% using indomethacin.
Fluid intake is restricted in PDA by18 neonatologists out of 63 (28%); 16
of these restrict fluids only in symptomatic babies while two restrict
fluid in all babies with PDA.
Most neonatologists continue feeds during medical treatment of a PDA with
only 6 (10%) stopping. Just over half of neonatologists restrict fluids
while treating baby for PDA (53%).
We asked clinical questions to all the neonatologists to understand the
threshold for treatment. Previously a similar question was asked to
neonatologists in the United States of America2. Neonatologists from UK
are much more conservative when compared to neonatologists from United
States when it comes to treating PDAs in preterm babies.
Interestingly 18% neonatologists from England said that they would treat a
moderately large PDA in a preterm baby, even if the baby is extubated and
on CPAP with 5% going on to surgical ligation if medical treatment fails
or is contraindicated.
No neonatologists from the UK would treat a moderate to large PDA in a
baby who is self-ventilating in air as opposed to one third of
Neonatologists from United States.
A second course of medical treatment is given by 80% neonatologists before
ligating PDA while 11% would give only one course of treatment before
ligating the duct if baby hasn't responded. Of those that responded, only
one neonatologist would give three courses of medical treatment before
ligating while 5 neonatologists felt that they would very rarely ligate a
PDA in preterm babies (1-5/every 5 years).
Echocardiography was performed by 79% of neonatologists themselves to
diagnose and treat PDA. In 46% of units there is no cardiology service and
the decision to treat PDA is made based on echocardiography findings of
the neonatologists. In these units babies require transfer to cardiology
centre for cardiology input. Onsite cardiology services are available in
18% of the units, with 20% of units having a paediatric cardiologist
visiting twice a week. Two units get cardiology input within 24 hrs of
request and a further two units have a paediatric cardiology visiting
twice a month.
In conclusion, significant variations exist in practice amongst
neonatologists when it comes to management of PDA in preterm babies. There
are significant variations in the number of babies treated on different
units by neonatologists claiming to follow same treatment strategy
suggesting different thresholds for treatment. The use of a prophylactic
treatment strategy is becoming rare. Most of neonatologists do
echocardiography themselves to make a decision regarding treatment of PDA,
with a half of units responding not having access to specialist cardiology
services on site.
Reference:
1. Bose CL, Laughon MM (2007) Patent ductus arteriosus: lack of evidence
for common treatments. Arch Dis Child Fetal Neonatal Ed 92:F498-F502
2. Jhaveri N et al: Feeding practices and patent ductus arteriosus
ligation preferences-are they related? Am J Perinatol 27: 667-674, 2009
It is my hypothesis that evolution selected
dehydroepiandrosterone(DHEA) because it optimizes replication and
transcription of DNA. Therefore DHEA levels affect all tissues and life
span. (I think selection for DHEA produced mammalia. "Hormones in
Mammalian Evolution," Rivista di Biologia / Biology Forum 2001; 94: 177-
184).
A case may be made that sufficient maternal DHEA is necessary both
for conception an...
It is my hypothesis that evolution selected
dehydroepiandrosterone(DHEA) because it optimizes replication and
transcription of DNA. Therefore DHEA levels affect all tissues and life
span. (I think selection for DHEA produced mammalia. "Hormones in
Mammalian Evolution," Rivista di Biologia / Biology Forum 2001; 94: 177-
184).
A case may be made that sufficient maternal DHEA is necessary both
for conception and full term pregnancy. A mother must produce sufficient
DHEA for herself as well as a fetus, until such time that the fetus starts
to produce DHEA sufficient to initiate birth and support for itself.
A mother who has difficulty initiating and supporting conception and
pregnancy may be low DHEA. If DHEA levels do affect all tissues, growth
and development of the child may be impaired, especially for the brain.
This may explain the findings of Seggers, et al.
End of Life Decision Making (EoL DM) in NICU is an extremely
sensitive issue. In our unit we have practiced shared DM for a long time
however as the authors write we did not come across any large studies
looking into parents perceptions of EoL DM in the long term.
1. We appreciate that telephonic interviews were discarded in this
paper to ensure accurate assessment of parent's self-perceived role. Also
interv...
End of Life Decision Making (EoL DM) in NICU is an extremely
sensitive issue. In our unit we have practiced shared DM for a long time
however as the authors write we did not come across any large studies
looking into parents perceptions of EoL DM in the long term.
1. We appreciate that telephonic interviews were discarded in this
paper to ensure accurate assessment of parent's self-perceived role. Also
interviews were conducted by three skilled interviewers and to ensure
reliability of themes extracted, however it is not clear if each parent
was interviewed three times, which if it did appeared a bit excessive.
Also it was not clear where the interview happened.
2. We noted that only 145 out of 258 eligible families were contacted. We
wonder whether inclusion of non-French speaking families would improve the
sample size?
3. As noted by the authors there were limitations in the sample with
overrepresentation of certain categories leading to limited possibility of
generalization of results.
Overall we appreciate the large amount of work into this study and hope
that such studies will prompt further large projects to improve our
strategies of decision making for these babies and families in times of
extreme grief.
Lumbar puncture is a blind procedure (no guidance about the path of
the lumbar puncture needle except for the sensory information that the
performer obtains about interspinous distance before inserting the needle
and upon puncturing the duramater).
1. We feel that the for a successful procedure, besides ensuring adequate
interspinous space to insert the needle by ensuring optimum position of
the patient it is very import...
Lumbar puncture is a blind procedure (no guidance about the path of
the lumbar puncture needle except for the sensory information that the
performer obtains about interspinous distance before inserting the needle
and upon puncturing the duramater).
1. We feel that the for a successful procedure, besides ensuring adequate
interspinous space to insert the needle by ensuring optimum position of
the patient it is very important to ensure that the patient is as calm and
comfortable as possible so that we donot have to chase a moving target
with a sharp needle. In our unit we use a few drops of 24% sucrose just
before positioning in lateral recumbent position. The observation in the
study that heart rate increases the most in sitting position (with or
without flexed hips) in itself suggests that the baby is far from calm at
that point.
2. The authors have concluded that 'Sitting flexed position of hips, which
seems to be suffciently safe and serve to enhance the success rate of a
LP' appears to be misrepresented as the authors have themselves recognized
that one of the limitations of this study is that there is absence of
performed lumbar puncture so success of the procedure cannot be gauged in
this study.
3. Sitting position may not be practically feasible in preterm and sick
ventilated neonates who have cardiovascular instability
I read with great interest the commentary by John D. Lantos on the SUPPORT study controversy. Dr. Lantos makes a compelling argument that the OHRP was misguided in its criticism of SUPPORT, primarily because both arms of the trial were within standard of care.1-2
Eligible infants whose parents refused to participate in SUPPORT received the same medical care, but instead of randomization via protocol, they were su...
Dear Editor,
I enjoyed reading this paper, but I have some comments about the statistics, which I think should have been picked up in the peer review process.
In the paper it is stated that the Bland Altman plot showed good correlation. Correlation should produce a coefficient and a p-value.
The paper does not report the value for the mean difference between the two methods. From the graph it...
We read with interest the thought provoking paper written by Dr. Bodeau-Livinecr and colleagues on behalf of the EPIPAGE. They concluded that compared with very preterm singletons, twins had higher mortality, no difference in severe deficiencies, but slightly lower Mental Processing Composite scores at 5 years. 1
The Authors suggest that although all the infants studied who were born preterm had been exposed...
The authors are to be thanked for looking into outcomes of fetuses identified with Critical Congenital Heart Disease (CCHD) based on the location of birth. Bennett et al (1) came to the same conclusion: that birth hospital had little impact on survival. As the authors point out, 75% of CCHD may be missed during prenatal evaluations. This means that the physicians at the non-specialty hospitals have to be able to recognize...
Dear Editor, The paper by Zareen et al. recently published in Archives, evaluates the effectiveness for suctioning meconium of various catheters and bulb syringes. The data provide useful information for caregivers of infants in the delivery room. [1] The authors describe meconium suctioning as a routine procedure. They quote: "However, recent guidelines recommend that, if the baby born with meconium stained fluid has a n...
Dear Editor, Thank you for the opportunity of answering to the comments of Chiesa (1) about our paper (2). First, the assay: Procalcitonin (PCT) was measured with an immunoluminometric, quantitative method, as in studies cited by us and by Chiesa. We used reagents Brahms and Berthold LB9507 luminometer (Dasit). The analytical signal, proportional to the concentration of the PCT in the sample, was converted into continuou...
We read with great interest the review "Patent ductus arteriosus-time to grasp the nettle" (Smith, Kissack, ADC F&N 2013; 98) which highlighted the controversies in PDA management and variation in management. Evidence to support the routine closure of the ductus arteriosus to improve neonatal morbidity remains inconclusive1. We recently conducted a survey on PDA management in neonatal units across England to understan...
It is my hypothesis that evolution selected dehydroepiandrosterone(DHEA) because it optimizes replication and transcription of DNA. Therefore DHEA levels affect all tissues and life span. (I think selection for DHEA produced mammalia. "Hormones in Mammalian Evolution," Rivista di Biologia / Biology Forum 2001; 94: 177- 184).
A case may be made that sufficient maternal DHEA is necessary both for conception an...
End of Life Decision Making (EoL DM) in NICU is an extremely sensitive issue. In our unit we have practiced shared DM for a long time however as the authors write we did not come across any large studies looking into parents perceptions of EoL DM in the long term.
1. We appreciate that telephonic interviews were discarded in this paper to ensure accurate assessment of parent's self-perceived role. Also interv...
Lumbar puncture is a blind procedure (no guidance about the path of the lumbar puncture needle except for the sensory information that the performer obtains about interspinous distance before inserting the needle and upon puncturing the duramater). 1. We feel that the for a successful procedure, besides ensuring adequate interspinous space to insert the needle by ensuring optimum position of the patient it is very import...
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