It is my hypothesis that the "secular trend," the increase in size
and earlier puberty occurring in children, is caused by an increase in the
percentage of individuals of higher testosterone. More specifically, I
suggest this is due to an increase in the percentage of mothers of higher
testosterone with time within the population. This exposes more fetuses to
increased maternal testosterone with time within the population....
It is my hypothesis that the "secular trend," the increase in size
and earlier puberty occurring in children, is caused by an increase in the
percentage of individuals of higher testosterone. More specifically, I
suggest this is due to an increase in the percentage of mothers of higher
testosterone with time within the population. This exposes more fetuses to
increased maternal testosterone with time within the population. This
causes permanet effects in the fetus which persist throughout the life
span. I suggest this is the cause of the parallel increases in morbidity
occurring within the population, such as obesity, cancer, breast cancer,
diabetes, etc., including prematurity, small for gestational age, etc.,
including less obvious gross effects which later contribute to "failing
schools" and other adverse behavioral outcomes in children.
Very well conceived, conducted and analysed study. Two comments:
1. In table 1 "received intrapartum antibiotics" should be "not received
intrapartum antibiotics" as later appears to be risk factor (OR>1) as
per text.
2. In table 2: scores allocated to risk factors are respective adjusted
odds ratios rounded to nearest integers. However, for per vaginal
examination 3 or more and for clinical chorioamnionitis, the score...
Very well conceived, conducted and analysed study. Two comments:
1. In table 1 "received intrapartum antibiotics" should be "not received
intrapartum antibiotics" as later appears to be risk factor (OR>1) as
per text.
2. In table 2: scores allocated to risk factors are respective adjusted
odds ratios rounded to nearest integers. However, for per vaginal
examination 3 or more and for clinical chorioamnionitis, the score
allocated is lower (6 versus 10 and 9 expected from value of OR). Any
specific reasons for this?
The team from Leeds have highlighted a very important area of
neonatal practice that is still seeking clarification and
enlightenment.Neonates do have a high incidence of reflux due to
physiologic and iatrogenic causes.These have been clearly highlighted in
this review.The choice and rationale for treating these babies clearly
shows that more work still needs to done before we can be sure that the
doctors and nurses are...
The team from Leeds have highlighted a very important area of
neonatal practice that is still seeking clarification and
enlightenment.Neonates do have a high incidence of reflux due to
physiologic and iatrogenic causes.These have been clearly highlighted in
this review.The choice and rationale for treating these babies clearly
shows that more work still needs to done before we can be sure that the
doctors and nurses are using appropriate measures to address the real
problem and not just propagating a placebo effect and using medications
that are not only unnecessary but potentially dangerous. The following
questions may help to concentrate the thinking about this problem.
Do we know if reflux in neonates is the cause of apnoeas? If not why
treat.
If we believe there is an association in the absence of aspiration, what
is the mechanism?.
It is agreed that the stomach of milk fed neonate is unlikely to suffer
from the effect of acid (buffering effect) what then is the rationale for
prescribing gaviscon? Could it be acting as a thickening agent?.
In the absence of proven oesophageal irritation or inflammation why do we
need to further reduce acid production by using H2 blocker or even worse a
proton pump inhibitor in the face of significant side effects with this
substance?.
Is there a place for using ph study with modified (acidified) feeds for
testing to demonstrate acid reflux and how significant is the position of
non acid reflux in this group of patients?.
Should positioning not be routinely practised as part of routine neonatal
care since gastro oesophageal reflux is common in this age group?
Surgical intervention in my experience is mainly offered for severe reflux
especially in patients with neurological disease or do the authors have a
different experience?
Is contrast study underused in these patients? And could this be a better
test in this uncertain field?.
Although I have raised a few questions, I appreciate the effort of
the authors who have tried to highlight the clear difficulties with the
investigation and treatment of reflux in this age group. Neonatologists in
the front line have to deal with problems using best evidence and in most
cases extrapolate from management strategies of older children. It is
however the time to look again at the evidence and adjust practice
accordingly. I remember not long ago cisapride was the standard prokinetic
agent used to treat gastroesophageal reflux in neonatal units even when
the evidence was not there. Tertiary neonatal units had in their
formularies this dangerous medicine which was dished out routinely and
thanks to the responsible authorities for the withdrawal of this product
from the UK for managing this problem,meaning that neonates have been
spared the dangers of arrhythmias.
I have an interest in paediatric gastroenterology and have practised in a
DGH with sessions of gastro-enterology at the Childrens hospital. In my
practice I have investigated neonates with symptoms suggestive of
gastroesophageal reflux and also suggested and advised on treatment
regimes.Having looked at the evidence,I still advice on ph studies with
it's flaws after initiation of treatment which had failed to resolve the
observed symptoms. In addition, neonates with acute life threatening
events in addition to Ph studies are subjected to contrast studies to make
sure no anatomical defect exists.
On the use of pharmacology agents, my emphasis is on the use of prokinetic
agents and less of H2 blockers or proton pump inhibitors unless evidence
of oesophagitis exists or the neonate is not enterally fed with milk while
symptomatic. In my experience, surgical intervention for managing
gastroesophageal reflux is only common with those neonates with
neurological problem with severe reflux disease.
The take home message for me after reading this article is that there is a
presumption by some medical practitioners that gastroesophageal Reflux
disease is associated with neonatal apnoeas and bradcardias and also that
no reliable form of investigation exists to confirm this and that
pharmacological agents though lacking in evidence remain the mainstay of
treatment. It also tells me that more research is needed to provide the
necessary answers. I will be very willing to be a participant in any such
study which is now over due.
References:
Peter CS, Sprodowski N, Bohnhorst B, et al Gastroesophageal reflux and
apnoea of prematurity: No temporal relationship.Pediatrics 2002;109;8 to
11.
Birch JL; Newell SJ; Gastroesophageal reflux disease in preterm
infants: Current management and diagnostic dilemmas ; Arch Dis Child fetal
Neonatal Ed 2009;94:F379-F383 doi:10.1136/adc.2008.149112
Dhillon AS, Ewer AK Diagnosis and management of gastroesophageal
reflux in preterm infants in neonatal intensive care units. Acta
Paediatrica 2004;93:88-93.
Omari TI, Haslam RR, Lundborg P, et al Effect of omeprazole on acid
gastroesophageal reflux and gastric acidity in preterm infants with
pathological acid reflux. J Pedr Gastroenterol Nutr 2007;44:41to44.
The challenge of making ethical decisions on 'end of life issues' in
neonates remains a hot and emotive topic for debate and individual
detailed analysis everytime it comes to light.This paper which discusses
the Swiss experience,highlights the variability in the application of
ethical judgement in this area of medicine.While this paper examined the
practical impact of implimenting the Swiss society of neonatology
guide...
The challenge of making ethical decisions on 'end of life issues' in
neonates remains a hot and emotive topic for debate and individual
detailed analysis everytime it comes to light.This paper which discusses
the Swiss experience,highlights the variability in the application of
ethical judgement in this area of medicine.While this paper examined the
practical impact of implimenting the Swiss society of neonatology
guideline on the care of infants born at the limit of viability in 2002,
its wider implication cannot be limited to this frame of reference. While
this study shows that the guideline was followed with its positive impact,
it also showed that this was variably applied between centres. It is clear
that the study to a large extent, focused on the outcomes of applying the
guideline it did not clearly tell us the process of convincing parents
that the decision reached to apply the guideline was the 'best'. In our
practice the dilemna faced on the shopfloor is highlighted in the
following case which strictly speaking is not in the category of 'limits
of viability', the ethical decisions required are very similar. We were
able to make decisions and make progress by applying suggestions from
available UK guidelines.
Fetal and neonatal medicine raises a number of ethical issues including
value of human life, role of best interests and deliberately ending life
or withholding life sustaining treatment. Families and health
professionals have to work together to make complex and emotionally
demanding decisions about a baby's treatment and care. The Royal College
of Paediatrics and Child health have published guidelines offering
recommendations to help with the thought process(1) More recently the
Nuffield Council on Bioethics has published a report which concentrates on
how a decision should be arrived at and who should make the decision(2).
We present here a case where we used the guidelines to help arrive at a
consensus about the baby.
Baby K was born at 39 wks gestation by emergency caesarian section due to
ruptured uterus. Baby was born in poor condition, was resuscitated and
effective ventilation established at 11 mins of life. She developed
seizures at one hour 40 mins of age and underwent total body cooling at
the regional tertiary centre. Parents wanted to withdraw care when she
first suffered seizures but were advised to continue care by the medical
team as her clinical state was evolving and enough information was not
available to predict outcome. She subsequently went on to develop
signs/symptoms consistent with Grade III hypoxic ischaemic
encephalopathy. Her Electroencephalogram (EEG) showed burst suppression
pattern on day 1 and day 7 of life. A Magnetic Resonance Imaging (MRI)
scan on day 28 of life showed injury to the thalamic and subcortical
structures with deep grey matter involvement consistent with asphyxial
injury in the perinatal period. At one month of age she remains self
ventilating in air, nasogastric tube fed, with severe neurological
compromise and absent gag reflex. Parents have remained consistent in not
wanting any resuscitation in the event of any deterioration. They would
like to take her home and in the event of any life threatening infection
would allow oral antibiotics only.
The RCPCH guideline describes five situations where it maybe ethical to
consider withholding or withdrawal of life sustaining treatment(1). Our
baby would fit in category 4 , the No purpose situation whether although
the patient maybe able to survive with treatment, the degree of physical
or mental impairment is so great that it would be unreasonable to expect
them to bear it.
Though the above guidelines are helpful, there may arise situations which
do not fit any of these categories. It is clear that decisions should
never be rushed and where doubt remains life sustaning treatment should be
continued till a consensus is reached between professionals and carers of
the child.
We found the Nuffield guidelines useful in clarifying what quality of life
means to different people and especially to use objective criteria to
define best interests. In the case of baby K, it was important not to feel
pressured to let her die since she was likely to be disabled and have no
quality of life. However, it was important to decide what was in her best
interests. We found the proposals of the Nuffield guidelines to address
best interests very helpful as a team in reaching consensus on
discussions about antibiotics, seeking medical attention, addressing
network of support to the family and understanding parents views.
Following the discussion, and based on the recommendations of the
guidelines we also took a legal opinion from the trust about this
decision.
We agree that NHS Trusts should explore ways of making sure that rapid
access to a clinical ethics committee should be available for situations
involving decisions like this.
Finally,though we acknowledge that this is a highly specialised area of
paediatrics, medical and nursing schools should invest more in training
health professionals, certainly individuals working in neonatal medicine,
on issues relating to law and ethics in fetal and neonatal medicine.
References
1. RCPCH guideline. Witholding and Withdrawing Life sustaining treatment
published May 2004.
2. Critical care decisions in fetal and neonatal medicine: ethical issues.
Report of the Nuffield Council on Bioethics 2007.Web
www.nuffieldbioethics.org.
3.Verhagen AAE, Dorscheidt JHHM, Engels B et al; Analgesics &
Neuromuscular blockers as part of end -of-life decisions in Dutch NICUs,
Arch Dis Child Fetal Neonatal Ed 2009:94: F434-
F438;doi;10.1136/adc.2008.14926.
Dear Sir
Professor Weindling questions why therapeutic hypothermia, an intervention
that may be incompletely proven, has been widely adopted into clinical
practice whereas other interventions such as delayed cord clamping (DCC)
have not.[1] DCC has been subjected to RCTs and meta-analyses all of which
demonstrate benefits for both term and premature infants with no evidence
of any harmful effects.[2] We consider that DCC s...
Dear Sir
Professor Weindling questions why therapeutic hypothermia, an intervention
that may be incompletely proven, has been widely adopted into clinical
practice whereas other interventions such as delayed cord clamping (DCC)
have not.[1] DCC has been subjected to RCTs and meta-analyses all of which
demonstrate benefits for both term and premature infants with no evidence
of any harmful effects.[2] We consider that DCC should not be viewed as an
intervention but rather as the allowance of a physiologically normal
transition from intra to extra uterine life. On the other hand immediate
or early cord clamping is clearly a medical intervention and one for which
there is no evidence of benefit to either the mother or the newborn
infant.
Early cord clamping deprives the newborn of the 20ml/kg of blood
which would have passed from the placenta to the newborn in the first few
minutes of life. Trials of only a 30 second delay in preterm infants have
shown worthwhile benefits as Professor Weindling states in his article.
Several bodies now recommend some delay in cord clamping where clinicians
feel that this is possible. For example, the Newborn Life Support Course
teaches that the umbilical cord "can usually be clamped at a minute after
delivery" and also that "very early clamping...can cause hypovolaemia".[3]
The World Health Organisation,[4] the International Federation of
Gynaecology and Obstetrics [5] and two Cochrane reviews [6,7] also support
DCC. Despite these recommendations most infants born in the UK will be
subjected to the intervention of immediate or early cord clamping.
Both our Units have a written policy of delayed cord clamping at
birth. We find that there is considerable difficulty in maintaining the
practice due to frequent changes of junior staff both in Obstetrics and
Paediatrics. The majority of junior staff come from units in which early
cord clamping is the norm. Staff are often concerned that DCC will cause
significant jaundice and polycythaemia and also delay resuscitative
efforts if these are required. Analysis of fifteen trials enrolling
nearly 2,000 infants showed no excess problems with jaundice or
respiratory distress. Polycythaemia was more frequent but not found to be
in any way harmful.[2] Whilst the policy of DCC is relatively easy to
institute in well term babies, staff find it more difficult to delay
clamping even for 30 seconds in premature infants and term infants who
appear in need of resuscitation. These infants, who are least likely to
get delayed clamping, are probably the ones who are most likely to benefit
from both the rapid transfusion of placental blood and also the
continuation of gas exchange via the placental circulation whilst regular
breathing becomes established.
The effectiveness of the placental circulation in the first few
minutes after birth was highlighted recently at one of our hospitals by
the case of a term infant born by elective caesarean section. The infant
was delivered onto the mother's thighs and became centrally pink within
the first minute of life. The infant's cord was clamped at two minutes
and he rapidly became cyanosed. Echocardiography at thirty minutes of age
demonstrated transposition of the great arteries with intact ventricular
septum and patent ductus arteriosus. Good oxygenation during the first
two minutes of life had been achieved because the placental circulation
was intact. We hypothesise that babies who have become significantly
hypoxic during the birth process may benefit from an intact umbilical cord
during the first few minutes of postnatal life whilst the infant is being
assessed and resuscitated. We believe that studies to evaluate how
resuscitation with an intact placental circulation could be achieved and
any benefits that may accrue are required.
Dr Andrew Gallagher
Consultant Paediatrician, Worcestershire Royal Hospital, Worcester, WR5
1DD
Mr David Hutchon
Consultant Obstetrician, Darlington Memorial Hospital, Darlington, DL3 6HX
References
1. Weindling AM. How has research in the last 5 years changed my
clinical practice? Arch Dis Child Fetal Neonatal Ed 2010; 95:F64-68.
2. Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord
in full-term neonates. Systematic review and meta-analysis of controlled
trials. JAMA 2007;297(11):1241-1252
3. Resuscitation Council (uk). Resuscitation at birth - Newborn life
support provider course manual. 2001
4. World Health Organization (WHO). WHO recommendations for the
prevention of postpartum haemorrhage. Geneva, Switzerland: World Health
Organization (WHO); 2007.
5. International Confederation of Midwives and the International
Federation of Gynecologists and Obstetricians. Management of the third
stage of labour to prevent post-partum haemorrhage 2003.
http://www.figo.org/projects/prevent (accessed Feb 2010)
6. Rabe H, Reynolds G, Diaz-Rossello J. Early vs delayed umbilical
cord clamping in preterm infants. Cochrane Database Syst Rev
2004;(4):CD003248.
7. McDonald SJ, Middleton P. Effect of timing of umbilical cord
clamping of term infants on maternal and neonatal outcomes. Cochrane
Database Syst Rev 2008;(2): CD004074.
We read with interest the paper by Dempsey and colleagues regarding
permissive hypotension in low birth weight infants. We are unsure that the
data as presented fully supports some of the conclusions drawn.
Those infants in whom hypotension was treated were deemed to be
unwell by the clinicians looking after them. This appears to have been a
sicker group at outset in terms of clinical and crib assessment. These...
We read with interest the paper by Dempsey and colleagues regarding
permissive hypotension in low birth weight infants. We are unsure that the
data as presented fully supports some of the conclusions drawn.
Those infants in whom hypotension was treated were deemed to be
unwell by the clinicians looking after them. This appears to have been a
sicker group at outset in terms of clinical and crib assessment. These
infants had a significantly lower blood pressure at all stages than the
other groups. This suggests that those infants were still in shock and the
adverse outcome may possibly be due to achieving inadequate therapeutic
goals, for whatever reason. We believe another conclusion for this study
may possibly be that inadequate resuscitation from shock is associated
with an adverse outcome and that this should be mentioned to give balance
to the discussion.
Since the case has not been made that hypotension, as defined in this
study, in sick infants is safe and in view of the very non-specific signs
of ill health in the neonate, we feel that this study does not suggest
that clinical equipoise exists with respect to trial of permissive
hypotension.
We would like to thank Mr Degraeuwe for his interest about our study
[1]. He is correct in stating that the confidence intervals are useful in
interpreting the diagnostic value of procalcitonin. The sensitivity,
specificity, positive and negative predictive values expressed as
percentages (95% CI) were respectively 100 (88-100), 65 (54-76), 67 (56-
78) and 100 (88-100) for PCT at the 0.6 ng/mL cut-off value.
We would like to thank Mr Degraeuwe for his interest about our study
[1]. He is correct in stating that the confidence intervals are useful in
interpreting the diagnostic value of procalcitonin. The sensitivity,
specificity, positive and negative predictive values expressed as
percentages (95% CI) were respectively 100 (88-100), 65 (54-76), 67 (56-
78) and 100 (88-100) for PCT at the 0.6 ng/mL cut-off value.
Mr Degraeuwe also commented on our method of calculating the number
of subjects. Several methods are available, and our biostatistics
department chose the comparison of percentages with objectives of
difference, power and alpha risk, as detailed in the article.
Therefore, we confirm the validity of our prudent conclusion. It
seems that procalcitonin can help in eliminating late-onset sepsis in
newborns hospitalized in a neonatal intensive care unit. These results
need to be confirmed in larger studies.
Aurélien Jacquot
Reference:
[1] Jacquot A, Labaune JM, Baum TP, Putet G, Picaud JC. Rapid quantitative
procalcitonin measurement to diagnose nosocomial infections in newborn
infants. Arch Dis Child Fetal Neonatal Ed. 2009;94:F345-8.
Sir,
Alvarez and colleagues1 report a clinically useful metanalysis on the
diagnostic value of subependymal pseudocysts and choroid plexus cysts seen
on neonatal cerebral ultrasound. It appears that complex subependymal
cysts at the caudothalamic groove may be more important clinically than
simple cysts here or in the choroid plexus. Their analysis did not expose
two other important conditions causing multiple and/or bila...
Sir,
Alvarez and colleagues1 report a clinically useful metanalysis on the
diagnostic value of subependymal pseudocysts and choroid plexus cysts seen
on neonatal cerebral ultrasound. It appears that complex subependymal
cysts at the caudothalamic groove may be more important clinically than
simple cysts here or in the choroid plexus. Their analysis did not expose
two other important conditions causing multiple and/or bilateral
subependymal pseudocysts in the neonate. Firstly glutaric aciduria type
1(GA1) 2,3, although rare, is important, as it is a potentially treatable
autosomal recessive disorder and signs such as macrocephaly may not be
present in the neonatal period. In GA1 the subependymal cysts tend to be
complex. Screening for this disorder is easy by urine organic analysis,
blood spot glutarylcarnitine and plasma total and free carnitine
estimations; if abnormal confirmation is by fibroblast glutaryl CoA
dehydrogenase activity3 and mutation analysis. The second disorder to
consider is in utero exposure to cocaine. While there is debate in the
literature, many studies have shown an association with subpendymal
cysts4, and subepedymal hemorrhage5. The effect on the foetus may be dose
dependent 5 and is likely vascular in basis. In these cases a detailed
antenatal history may identify the diagnosis.
1. Fernandez Alvarez JR, Amess PN, Gandhi RS, Rabe H. Diagnostic
value of subependymal pseudocysts and choroid plexus cysts on neonatal
cerebral ultrasound: a meta-analysis. Arch Dis Child Fetal Neonatal Ed.
2009 ;94(6):F443-F446.
2. Twomey EL,Naughten ER, Donoghue VB ,Ryan S. Neuroimaging findings in
glutaric aciduria type 1 .Pediatr Radiol 2003 ;33: 823–830.
3. Hartley L.M, Khwaja O. S, Verity C.M, Glutaric Aciduria Type 1 and
Nonaccidental Head Injury. Pediatrics 2001;107(1):174-175 .
4. Smith LM, Qureshi N, Renslo R, Sinow RM. Prenatal cocaine exposure and
cranial sonographic findings in preterm infants. J Clin Ultrasound.
2001;29(2):72-77.
5. Frank D.A, McCarten K.M, , Robson C.D, Mirochnick M, Cabral H, Park H,
Zuckerman B. Level of In Utero Cocaine Exposure and Neonatal Ultrasound
Findings. Pediatrics. 1999;104(5 Pt 1):1101–1105.
Verhagen et al describe the use of analgesics, sedatives and
neuromuscular blockers during reorientation of care to compassionate
measures in Groningen, the Netherlands (1). The authors draw attention to
the fact that in 16% of such events, neuromuscular blockers (NMBs) were
used. In cases, NMBs were used to eliminate gasping after the
endotracheal tube had been removed.
Diagnoses and reasons for administering NMBs afte...
Verhagen et al describe the use of analgesics, sedatives and
neuromuscular blockers during reorientation of care to compassionate
measures in Groningen, the Netherlands (1). The authors draw attention to
the fact that in 16% of such events, neuromuscular blockers (NMBs) were
used. In cases, NMBs were used to eliminate gasping after the
endotracheal tube had been removed.
Diagnoses and reasons for administering NMBs after the decision to
reorient care are described in 55 infants in the study. In two cases it
was to prevent gasping, in 14 to stop established gasping and in one case
the reason is stated as “to end life”. Futhermore, it was described as
requested by parents in 2 cases. Dr Ward Platt has written a thoughtful
editorial about this retrospective Dutch survey (2). He writes, “In the
UK and perhaps elsewhere I suspect that the administration of such agents
to a baby not already paralysed would be much less likely because it is
more difficult to justify the use of NMBs on the basis of “double effect”.
Because Archives of Diseases in Childhood is the Journal of the United
Kingdom’s RCPCH, we feel it is important to make clear that administration
of NMBs after extubation of a patient is currently illegal. Double effect
might be argued in the event of administering intravenous sedatives. The
used of NMBs after assisted ventilation has been withdrawn has the single
purpose of ending respirations, thus bringing about the patient’s death.
C Piyasena, IA Laing.
Neonatal Unit, Simpson Centre for Reproductive Health, Royal Infirmary of
Edinburgh, EH16 4SA
Correspondence to: Dr I A Laing, Neonatal Unit, Simpson Centre for
Reproductive Health, Royal Infirmary of Edinburgh, EH16 4SA
Competing interests: None
REFERENCES
1) Verhaagen AAE, Dorscheidt JHHM, Engels B et al. Analgesics,
sedatives and neuromuscular blockers as part of end-of-life decisions in
Dutch NICUs. Arch Dis Child Fetal Neonatal Ed 2009;94:F434-F438
2) Ward Platt M. End of life care in Holland. Fantoms. Arch Dis Child
Fetal Neonatal Ed 2009;94:F391
I am writing this letter in reference to the article "Rapid
quantitative procalcitonin measurement to diagnose nosocomial infections
in newborn infants" by Jacquot et al. [1] The aim of this study was to
investigate the diagnostic accuracy of procalcitonin in neonatal
nosocomial infections. However, the flawed methodology and the incomplete
reporting preclude a reliable conclusion with respect to the d...
I am writing this letter in reference to the article "Rapid
quantitative procalcitonin measurement to diagnose nosocomial infections
in newborn infants" by Jacquot et al. [1] The aim of this study was to
investigate the diagnostic accuracy of procalcitonin in neonatal
nosocomial infections. However, the flawed methodology and the incomplete
reporting preclude a reliable conclusion with respect to the diagnostic
performance of procalcitonin for ruling out nosocomial sepsis.
With an eye to the study objective, the power calculation should have
been based on the expected sensitivity, specificity, predictive accuracy
and their minimal acceptable lower confidence limit. [2,3]
The authors omitted to report the 95% confidence interval for the
estimates of sensitivity and negative predictive value. This prevents the
reader of appreciating the range within which the true values are likely
to lie [4]. Therefore, I backward calculated the true positive (30), false
positive (15), false negative (0), and true negative (28) test results.
Using a commercial statistical package (Prism 5.0 GraphPad software, San
Diego, CA, USA), the sensitivity (95% CI) can be calculated to be 1
(0.8843 to 1) whereas the accuracy of a negative test is 1 (0.8766 to 1).
As yet, given this (im)precision, procalcitonin cannot be used to
rule out nosocomial infection in the NICU at the moment of suspicion.
References:
1. Jacquot A, Labaune JM, Baum TP, Putet G, Picaud JC. Rapid
quantitative procalcitonin measurement to diagnose nosocomial infections
in newborn infants. Arch Dis Child Fetal Neonatal Ed 2009;94:F345-8.
2. Flahault A, Cadilhac M, Thomas G. Sample size calculation should
be performed for design accuracy in diagnostic test studies. J Clin
Epidemiol 2005;58:859-62.
3. Buderer NM. Statistical methodology: I. Incorporating the
prevalence of disease into the sample size calculation for sensitivity and
specificity. Acad Emerg Med 1996;3:895-900.
4. Harper R, Reeves B. Reporting of precision of estimates for
diagnostic accuracy: a review. BMJ 1999;318:1322-3.
It is my hypothesis that the "secular trend," the increase in size and earlier puberty occurring in children, is caused by an increase in the percentage of individuals of higher testosterone. More specifically, I suggest this is due to an increase in the percentage of mothers of higher testosterone with time within the population. This exposes more fetuses to increased maternal testosterone with time within the population....
Very well conceived, conducted and analysed study. Two comments: 1. In table 1 "received intrapartum antibiotics" should be "not received intrapartum antibiotics" as later appears to be risk factor (OR>1) as per text. 2. In table 2: scores allocated to risk factors are respective adjusted odds ratios rounded to nearest integers. However, for per vaginal examination 3 or more and for clinical chorioamnionitis, the score...
The team from Leeds have highlighted a very important area of neonatal practice that is still seeking clarification and enlightenment.Neonates do have a high incidence of reflux due to physiologic and iatrogenic causes.These have been clearly highlighted in this review.The choice and rationale for treating these babies clearly shows that more work still needs to done before we can be sure that the doctors and nurses are...
The challenge of making ethical decisions on 'end of life issues' in neonates remains a hot and emotive topic for debate and individual detailed analysis everytime it comes to light.This paper which discusses the Swiss experience,highlights the variability in the application of ethical judgement in this area of medicine.While this paper examined the practical impact of implimenting the Swiss society of neonatology guide...
Dear Sir Professor Weindling questions why therapeutic hypothermia, an intervention that may be incompletely proven, has been widely adopted into clinical practice whereas other interventions such as delayed cord clamping (DCC) have not.[1] DCC has been subjected to RCTs and meta-analyses all of which demonstrate benefits for both term and premature infants with no evidence of any harmful effects.[2] We consider that DCC s...
We read with interest the paper by Dempsey and colleagues regarding permissive hypotension in low birth weight infants. We are unsure that the data as presented fully supports some of the conclusions drawn.
Those infants in whom hypotension was treated were deemed to be unwell by the clinicians looking after them. This appears to have been a sicker group at outset in terms of clinical and crib assessment. These...
We would like to thank Mr Degraeuwe for his interest about our study [1]. He is correct in stating that the confidence intervals are useful in interpreting the diagnostic value of procalcitonin. The sensitivity, specificity, positive and negative predictive values expressed as percentages (95% CI) were respectively 100 (88-100), 65 (54-76), 67 (56- 78) and 100 (88-100) for PCT at the 0.6 ng/mL cut-off value.
Mr...
Sir, Alvarez and colleagues1 report a clinically useful metanalysis on the diagnostic value of subependymal pseudocysts and choroid plexus cysts seen on neonatal cerebral ultrasound. It appears that complex subependymal cysts at the caudothalamic groove may be more important clinically than simple cysts here or in the choroid plexus. Their analysis did not expose two other important conditions causing multiple and/or bila...
Verhagen et al describe the use of analgesics, sedatives and neuromuscular blockers during reorientation of care to compassionate measures in Groningen, the Netherlands (1). The authors draw attention to the fact that in 16% of such events, neuromuscular blockers (NMBs) were used. In cases, NMBs were used to eliminate gasping after the endotracheal tube had been removed. Diagnoses and reasons for administering NMBs afte...
Dear Sir
I am writing this letter in reference to the article "Rapid quantitative procalcitonin measurement to diagnose nosocomial infections in newborn infants" by Jacquot et al. [1] The aim of this study was to investigate the diagnostic accuracy of procalcitonin in neonatal nosocomial infections. However, the flawed methodology and the incomplete reporting preclude a reliable conclusion with respect to the d...
Pages