Sequential screening for psychosocial and behavioural risk during pregnancy in a population of urban African Americans.

OBJECTIVE: Screening for psychosocial and behavioural risks, such as depression, intimate partner violence, and smoking, during pregnancy is considered to be state of the art in prenatal care. This prospective longitudinal analysis examines the added benefit of repeated screening, compared with a single screening, in identifying such risks during pregnancy. DESIGN: Data were collected as part of a randomised controlled trial to address intimate partner violence, depression, smoking, and environmental tobacco smoke exposure in African American women. SETTING: Prenatal care sites in the District of Columbia serving mainly women of minority background. POPULATION: A cohort of 1044 African American pregnant women in the District of Columbia. METHODS: Mothers were classified by their initial response (acknowledgement of risks), and these data were updated during pregnancy. Risks were considered new if they were not previously reported. Standard hypothesis tests and logistic regression were used to predict the acknowledgment of any new risk(s) during pregnancy. MAIN OUTCOME MEASURES: New risks: psychosocial variables to understand what factors might help identify the acknowledgement of additional risk(s). RESULTS: Repeated screening identified more mothers acknowledging risk over time. Reported smoking increased by 11%, environmental tobacco smoke exposure increased by 19%, intimate partner violence increased by 9%, and depression increased by 20%. The psychosocial variables collected at the baseline that were entered into the logistic regression model included relationship status, education, Medicaid, illicit drug use, and alcohol use during pregnancy. Among these, only education less than high school was associated with the acknowledgement of new risk in the bivariate analyses, and significantly predicted the identification of new risks (OR 1.39, 95% CI 1.01-1.90). CONCLUSIONS: It is difficult to predict early on who will acknowledge new risks over the course of pregnancy, and thus all women should be screened repeatedly to allow for the identification of risks and intervention during prenatal care.

Maternal obesity, associated complications and risk of prematurity.

OBJECTIVE: We aimed at (a) examining the rates of obesity over a 12-year period; (b) studying the effect of obesity and morbid obesity on gestational age and birth weight and (c) determining the influence of race on the association between maternal obesity and the gestational age of a newborn. STUDY DESIGN: We conducted a retrospective analysis using data from the perinatal data set of mothers delivering at the George Washington University between 1992 and 2003. We stratified mother/infant pairs (n=14 183) into three groups on the basis of maternal prepregnancy body mass index (BMI): not obese (BMI<30), obese (BMI 30 to 39) and morbidly obese (BMI> or =40). We identified all spontaneous and induced preterm deliveries in each group. Bivariate and multivariate analyses were conducted to control for significant differences between groups. RESULT: We identified obesity in 1707 (12%) and morbid obesity in 415 (3%) of the mothers. Obesity and morbid obesity increased over time during the study period. In crude analysis, mothers with obesity and morbid obesity were more likely to deliver prematurely (16.7 and 20.3%, respectively) when compared with nonobese women (14.5%), and were also more likely to have other complications including smoking, anemia, hypertension, diabetes and cesarean delivery. When controlling for these complications in a logistic regression model, obesity and morbid obesity were not associated with prematurity. CONCLUSION: There is no direct link between obesity and prematurity. Prematurity is more likely caused by medical complications that frequently occur in obese women. Further studies are needed on this growing population to test whether providing adequate prenatal care can control the associated medical conditions and subsequently ameliorate the rate of prematurity.

Can delivery room management impact the length of hospital stay in premature infants?

OBJECTIVES: To evaluate the impact of initiating early nasal continuous positive airway pressure (ENCPAP) on the length of hospital stay (LOS) for the very low birth weight (VLBW) infants. STUDY DESIGN: LOS at the George Washington University Hospital (GW) after the institution of ENCPAP policy was compared to benchmark values using two-tail t-tests. The incidence of neonatal morbidity was calculated using Bonferroni corrected 95% confidence interval as compared to benchmark rates (alpha=0.001). Comparisons were repeated after stratification of the population into four birth weight subcategories: group A (GrpA) (501 to 750 g), GrpB (751 to 1000 g), GrpC (1001 to 1250 g) and GrpD (1251 to 1500 g). RESULTS: We studied 228 consecutive VLBW infants (birth weight: 995+/-294 g and gestational age: 27.7+/-2.7 weeks). Compared to benchmark values, the GW experience was associated with a significant reduction of 5.1 days in LOS (55.9+/-25.2 vs 61+/-32 days; P=0.04). The decrease in LOS was consistent in all subgroups, but was most noticeable in infants of the smallest weight subcategory (LOS in GrpA=86+/-21 vs 104+/-32, P=0.004; in GrpB=69.9+/-16.7 vs 79+/-27, P=0.018; in GrpC=48.2+/-13 vs 56+/-22, P<0.001 and in GrpD=31.7+/-12.5 vs 40+/-19, P=0.003). In the overall population, a lower incidence of chronic lung disease (CLD) (17.8 vs 29%, P<0.001) was also noted. There were no differences in mortality rates (9 vs 14%), or the incidence of necrotizing enterocolitis (NEC) (8 vs 6%) or intraventricular hemorrhage (6.2 vs 9%) between GW and the established benchmark rates. CONCLUSION: ENCPAP may reduce LOS in VLBW infants in our study population. This relatively shorter LOS was associated with a lower incidence of CLD, which may be a contributing factor.

A comparison of neonatal mortality risk prediction models in very low birth weight infants.

BACKGROUND: Risk-adjusted severity of illness is frequently used in clinical research and quality assessments. Although there are multiple methods designed for neonates, they have been infrequently compared and some have not been assessed in large samples of very low birth weight (VLBW; <1500 g) infants. OBJECTIVES: To test and compare published neonatal mortality prediction models, including Clinical Risk Index for Babies (CRIB), Score for Neonatal Acute Physiology (SNAP), SNAP-Perinatal Extension (SNAP-PE), Neonatal Therapeutic Interventions Scoring System, the National Institute of Child Health and Human Development (NICHD) network model, and other individual admission factors such as birth weight, low Apgar score (<7 at 5 minutes), and small for gestational age status in a cohort of VLBW infants from the Washington, DC area. METHODS: Data were collected on 476 VLBW infants admitted to 8 neonatal intensive care units between October 1994 and February 1997. The calibration (closeness of total observed deaths to the predicted total) of models with published coefficients (SNAP-PE, CRIB, and NICHD) was assessed using the standardized mortality ratio. Discrimination was quantified as the area under the curve (AUC) for the receiver operating characteristic curves. Calibrated models were derived for the current database using logistic regression techniques. Goodness-of-fit of predicted to observed probabilities of death was assessed with the Hosmer-Lemeshow goodness-of-fit test. RESULTS: The calibration of published algorithms applied to our data was poor. The standardized mortality ratios for the NICHD, CRIB, and SNAP-PE models were.65,.56, and.82, respectively. Discrimination of all the models was excellent (range:.863-.930). Surprisingly, birth weight performed much better than in previous analyses, with an AUC of.869. The best models using both 12- and 24-hour postadmission data, significantly outperformed the best model based on birth data only but were not significantly different from each other. The variables in the best model were birth weight, birth weight squared, low 5-minute Apgar score, and SNAP (AUC =.930). CONCLUSION: Published models for severity of illness overpredicted hospital mortality in this set of VLBW infants, indicating a need for frequent recalibration. Discrimination for these severity of illness scores remains excellent. Birth variables should be reevaluated as a method to control for severity of illness in predicting mortality.

Characterization of early activation events in cord blood B cells after stimulation with T cell-independent activators.

Human neonates are immunologically immature, particularly in their humoral antibody responses to T cell-independent antigens, as exemplified by their increased susceptibility to infections with polysaccharide-encapsulated bacteria. To clarify the mechanism(s) underlying the unresponsiveness of neonates to polysaccharide antigens, we used an in vitro model with neonatal cord blood cells that has been shown to mimic surface Ig-dependent signaling in the adult by T cell-independent antigens. We studied the ability of cord blood human B cells to become activated after ligation of their surface Ig by unconjugated anti-Ig, dextran-conjugated anti-Ig, and Staphylococcus aureus Cowan A1, and compared their response with that of adult B cells. After the addition of nanogram concentrations of anti-Ig-dextran, neonatal cord blood B cells proliferated at levels comparable to that observed with adult B cells. The majority of cord blood B cells showed a marked rise in intracellular calcium, increased surface expression of human leukocyte antigen DR, and an increase in cell size. Direct activation of protein kinase C by phorbol esters in neonatal B cells led to cellular proliferation, and when combined with anti-Ig, a synergistic effect on proliferation was observed. These data suggest that the unresponsiveness of human neonates to polysaccharide antigens does not represent an inability of these antigens to induce early activation events in circulating B cells.

Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis.

OBJECTIVES: This study compares stool colonization and incidence of sepsis in human milk-fed (HM) and formula-fed (FF) intensive care nursery (ICN) patients. STUDY DESIGN: Infants recruited prospectively were fed HM based on the decision of their mothers (59 HM and 114 FF). The incidence of sepsis was determined during the following three intervals: period 1, first 10 days of life; period 2, 11 to 24 days; and period 3, 25 to 38 days. RESULTS: Frequency of Escherichia coli and Enterococcus sp. colonization was increased in HM infants. The incidence of sepsis was 9.5% in period 1 (5% in HM vs 10% in FF), 17.2% in period 2 (9% in HM vs 20% in FF), and 12.5% in period 3 (0% in HM vs 15% in FF). The odds ratio for sepsis in HM infants was 0.4, the 95% limits 0.15 to 0.95, p = 0.04. CONCLUSIONS: HM feeding in the ICN has a protective effect against nosocomial sepsis, which is unrelated to its influence on gastrointestinal (GI) flora.

Staphylococcus epidermidis sepsis in the intensive care nursery: a characterization of risk associations in infants < 1,000 g.

We undertook to determine Staphylococcus epidermidis colonization patterns and risks of sepsis in a cohort of 82 consecutive intensive care nursery admissions (birth weight 1,285 +/- 57 g), with 24 infants weighing < 1,000 g at birth. Colonization was determined by skin and stool cultures collected at three time points. Multiple neonatal variables were classified into three intervals preceding the time of sample collection including the occurrence of S. epidermidis sepsis. 16 infants (20%) developed S. epidermidis sepsis. 81% of these episodes occurred in infants < 1,000 g. Skin colonization was nearly universal at all sampling points. Rectal colonization was 63.6% initially (10 +/- 0.4 days), then declined to 32% by the third sample (37 +/- 0.4 days). Neither prevalence of skin nor rectal colonization influenced the incidence of sepsis significantly. Statistically significant risk associations for sepsis for the entire intensive care nursery population included: low birth weight, gestational age, presence of a central line, and delayed feeding. For infants < 1,000 g the occurrence of sepsis during the second study time period (54% of the episodes) was associated with preceding steroid exposure. During the third study time period, birth weight and delayed attainment of full enteral feeds showed a statistically significant association with sepsis. We conclude that infants < 1,000 g are at an increased risk of S. epidermidis sepsis. Extreme immaturity, steroid therapy, and prolonged hyperalimentation are all significant risk associations.

Membrane antigen and ligand receptor expression on neonatal monocytes.

The monocyte/macrophage cell lineage is an essential component of host defense. Functional deficiencies have been described in neonatal monocytes, but knowledge of membrane antigen and receptor ligand expression in neonatal monocytes is incomplete. In this study, antigen and receptor ligand expression of cord blood monocytes (CBM) was examined and compared to adult peripheral blood monocytes (PBM). Leu-M3 and Leu-M5 antigens were shown to be present on all CBM. Using dual fluorescence microfluorometry, the percentage and intensity of expression of HLA-DR, CD4 antigens, Fc gamma and IL-2 receptors (IL-2R) on Leu-M3+ and Leu-M5+ CBM were compared to PBM. A lower percentage of expression of HLA-DR+ (87 +/- 3% vs. 95 +/- 1%, p = 0.02) and FC gamma RII+ (96 +/- 1% vs. 99 +/- 0.2%, p = 0.04) was noted on CBM. CD4, FC gamma RI, and FC gamma RIII expression on CBM were comparable to PBM. LPS stimulation of CBM induced IL-2R expression and enhanced HLA-DR antigen expression as seen previously on PBM. These findings indicate that CBM are phenotypically comparable to adult PBM with deficiencies localized only to a few specific areas.

Incidence of Candida parapsilosis colonization in an intensive care nursery population and its association with invasive fungal disease.

We have studied 82 consecutive intensive care nursery admissions to determine rates of colonization and incidence of fungal sepsis. Cultures were obtained from stool, gastric aspirate and skin at three different times. Infants studied ranged in gestational age from 23 to 38 weeks (mean +/- SEM 29 +/- 0.4 weeks). Nineteen percent of all infants were colonized with Candida sp.; stools were more frequently culture-positive than skin or gastric aspirates. Colonized infants began enteral feeds at a later time compared with noncolonized neonates. Five of the study infants developed fungal sepsis. One had congenital Candida albicans sepsis and died at 10 days of age; the other four had Candida parapsilosis sepsis and survived. The development of C. parapsilosis sepsis was significantly associated with gastrointestinal colonization. Our results suggest that early initiation of enteral feeds decreases gastrointestinal colonization with C. parapsilosis. Gastrointestinal colonization was strongly associated with the subsequent development of C. parapsilosis sepsis in this group of high risk neonates.

Mononuclear phagocytic cells in human milk: HLA-DR and Fc gamma R ligand expression.

The study of the cellular immune components of human milk is essential in the understanding of the role human milk may play in protecting the nursing infant against infection. We have investigated some phenotypic characteristics of breast milk macrophages (BMM) and have compared them to the characteristics of adult peripheral blood monocytes (PBM) by using dual parameter flow microfluorometry. Most BMM expressed the monocyte/macrophage markers Leu-M3 and Leu-M5. The latter marker was present in high density (bright) on BMM, but the density of expression of Leu-M3 was higher on PBM than on BMM [median fluorescence intensity (MFI) 409 +/- 105 versus 203 +/- 106, p = 0.02]. The percentage of BMM (98 +/- 2) that expressed the HLA-DR antigen did not differ significantly from PBM, but the density of expression was higher on BMM (MFI 318 +/- 56 versus 264 +/- 41, p = 0.03). The HLA-DR expression of BMM was further enhanced after incubation with interferon-gamma for 36 h; however, receptor for interleukin-2 could not be induced on BMM by this treatment. The expression of the three classes of Fc gamma R was lower on BMM than on PBM, in percentage (Fc gamma RI 56 +/- 23 versus 79 +/- 17%, p = 0.02), density of expression (Fc gamma RIII MFI 71 +/- 20 versus 153 +/- 73, p = 0.002), or both (Fc gamma RII 74 +/- 22% versus 94 +/- 12%, p = 0.02, and MFI 115 +/- 53 versus 202 +/- 59, p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial contaminants of collected and frozen human milk used in an intensive care nursery.

BACKGROUND: Use of human milk for preterm and high-risk neonates conveys many potential benefits but also poses practical difficulties. This prospective study examined the prevalence and degree of bacterial contamination of human milk used in the intensive care nursery. METHODS: One hundred eight milk samples collected from 40 mothers were tested for contamination. Samples from mothers whose milk showed a high degree of contamination were retested after counseling on collection methods. RESULTS: Only 12.5% of the samples showed no bacterial growth. Of the contaminated samples, 38% contained > 30,000 colony-forming units/ml. The most common contaminants were Staphylococcus epidermidis (82%) and Acinetobacter (9%), but other contaminants were also encountered. CONCLUSIONS: There were not statistically identifiable common characteristics of mothers whose milk showed abundant bacterial contamination. Only 30% of these mothers showed improvement in the degree of contamination after counseling regarding techniques of milk collection.

Aerobes isolated in fecal microflora of infants in the intensive care nursery: relationship to human milk use and systemic sepsis.

BACKGROUND: Staphylococcus epidermidis is a leading cause of nosocomial sepsis in the intensive care nursery. The relationship between rates of gastrointestinal colonization and the incidence of systemic sepsis with S. epidermidis in hospitalized neonates is under investigation. METHODS: In this study, we enrolled 46 infants consecutively admitted to the intensive care nursery (mean +/- standard deviation, birth weight 1300 +/- 337 gm, gestational age 29.4 +/- 2.2 weeks). At the time of enrollment, infants had been fed enterally for at least 1 week (28 were fed formula and 18 received their own mothers' frozen milk). Stool samples were collected when infants were 2 to 3 weeks of age (16.3 +/- 7.4 days). RESULTS: Aerobic stool flora were present in 65% of all patients. Human milk use was associated with a significant increase in the presence of aerobic stool flora (78% vs 46%, p = 0.035), as well as more frequent isolation of S. epidermidis. The incidence of S. epidermidis sepsis was 33% in those infants whose stool specimens grew S. epidermidis and 3.5% in those whose stool specimens did not (p < 0.01). CONCLUSIONS: These findings suggest the gastrointestinal tract as a possible site of entry for S. epidermidis in the hospitalized preterm infant. In addition, frozen human milk may be a vehicle for gastrointestinal S. epidermidis colonization.

Prevalence and toxigenicity of Clostridium difficile isolates in fecal microflora of preterm infants in the intensive care nursery.

Fecal isolates of Clostridium difficile and its toxin B were followed prospectively in 50 preterm intensive care nursery (ICN) patients. The first stool specimen was obtained after 1 week of enteral feeding, at 15 +/- 1 days of life, and 2 more specimens were collected at 2-week intervals, 24 +/- 1 and 32 +/- 2 days of life. The stools were cultured for C. difficile, and tested for C. difficile toxin B. In the first specimen 15% of stools grew C. difficile. In the second specimen C. difficile isolation rates increased to 33% and plateaued. Toxin B was detected in 71, 93 and 100% of culture-positive stools in the first, second, and third specimens, respectively. C. difficile colonization was not associated with a higher incidence of necrotizing enterocolitis or diarrhea, and using precollected, frozen human milk did not protect from C. difficile colonization.

A study of some trace elements in fingernail and hair of Egyptian bilharzial patients using short neutron activation.

The concentration of 10 elements has been determined in fingernail and hair of four groups representing normal and hepatosplenic (bilharzial) subjects. Samples were collected from rural inhabitants to the east of Alexandria City and irradiated with thermal neutrons from a Triga Mark III Reactor, for 10 minutes. Measurements were made using HPGe detector, ADC and PDP 11/34. The analysis were performed using the RAYGUNprogram. The results showed an increase in the concentration of Al, Cl and I in both fingernail and hair of bilharzial patients than normal while Mg, Ca, K, Mn, Cu, and Sr decreased. Most of the elements showed a higher concentration in fingernail than in hair.

Impaired interferon-alpha enhancement of neonatal monocyte phagocytosis.

Monocyte phagocytic activity was tested in 10 healthy term newborns using a latex phagocytic assay. The baseline phagocytic activity in the cord blood monocytes (37.7 +/- 3.8%) was comparable to adult controls (38.5 +/- 9.4%). When enhanced with 1,000 U/ml of alpha-interferon, the phagocytic activity was lower in cord blood monocytes (40.5 +/- 3.4%) than in the adult controls (47.9 +/- 10.6%), but this difference reached statistical significance only when the cord blood monocytes were enhanced with 2,000 U/ml reaching 43.6 +/- 4.3% in cord blood monocytes, as compared to 54.6 +/- 9.6% in adult controls. These findings may explain an inherent functional deficiency in the neonatal mononuclear phagocytic system which may not be evident during the quiescent phase of monocyte/macrophage activity, but may become apparent during an infectious challenge.

Lymphocyte populations and responses to mitogens in infants of diabetic mothers.

A group of 10 infants of diabetic mothers, born prematurely by Caesarian section was compared to an age-matched group of premature controls and to full-term newborns. There was no difference between the three groups in terms of lymphocyte populations at birth. The percentage of T-cells in the three groups was significantly lower than in adults but reached adult levels at 1 month of age. The mitogenic responses in infants of diabetic mothers was found significantly higher than in the two control groups at birth and remained so at one month of age. The suppressor T-cell activity was decreased in infants of diabetic mothers as compared with controls.