Cerebral and splanchnic near-infrared spectroscopic dataset in premature newborns receiving packed red blood cell transfusion.

This article presents the near-infrared spectroscopy (NIRS) dataset of cerebral (StO2c) and splanchnic (StO2s) oxygenation in 29 stable premature infants admitted to a tertiary neonatal intensive care unit who received elective packed red blood cell transfusion (PRBCT) to treat anemia of prematurity. StO2c and StO2s data were prospectively recorded continuously from at least 4 hours before the beginning of PRBCT until 24 hours after its completion, using a 4-wavelength near-infrared spectroscopy (NIRS) monitor (FORE-SIGHT® absolute cerebral oximeter, CASMED, Branford, Connecticut, 06405 USA). StO2 data were downloaded as an analog output at a sampling rate of 1000Hz and aligned along the time axis in LabChart reader format (.adicht files) using a PowerLab data acquisition system [1] (PowerLab®, ADInstruments, Sydney, Australia). The .adicht files were then converted into .mat file format using a Python script (PythonTM version 3.7.3 [2]) and resampled at 1Hz for faster processing. Data that could not be physiologically explained (e.g., the absence of variability, [3] a 30% step change in StO2 between two subsequent data points for StO2[4]), as well as the data during the period of 'cares' were presumed to be artefactual and were replaced with 'NaN' or 'Not a Number' which is recognised by Matlab [5] (MATLAB 9.3, The MathWorks, Inc., Massachusetts, United States) and ignored for all subsequent processing while maintaining the correct time point of the StO2 signals. The data were then exported into Microsoft Excel format. The splanchnic cerebral oxygenation ratio (SCOR) was calculated as the ratio of StO2s/StO2c. A 4-hour mean pre-transfusion values (StO2s 0, StO2c 0, SCOR 0) and post-transfusion hourly mean values (1-28) were determined. Secondary data were derived from a Mixed Models for Repeated Measures (MMRM) analysis with the time point fitted as a fixed effect and the infant fitted as a random effect. The MMRM was used to perform paired comparisons between pre-transfusion and each of the post-baseline values. This article only provides the NIRS data. The secondary data and demography can be found in the article "Splanchnic-Cerebral Oxygenation Ratio associated with Packed Red Blood Cell Transfusion in preterm infants", published in Transfusion Medicine. [6] The data will be of use to researchers in neonatology, transfusion medicine, and physiology to understand changes in cerebral and splanchnic oxygenation associated with PRBCT. Data collection, processing, and analysis can be remodelled in larger multicentric randomised controlled studies to evaluate the effect of transfusion and feeding on transfusion-associated necrotising enterocolitis. The data are also helpful to explore the autoregulatory behaviour of the brain and gut when the oxygen content of blood is increased by administering PRBCT.

Splanchnic-cerebral oxygenation ratio associated with packed red blood cell transfusion in preterm infants.

BACKGROUND: Splanchnic-cerebral oxygenation ratio (SCOR), the ratio of splanchnic tissue oxygen (StO2 s) to simultaneously measured cerebral tissue oxygen (StO2 c), has been described as a surrogate to detect impaired splanchnic oxygenation associated with hypoperfusion status such as necrotizing enterocolitis. This concept is based on the presumption that any change in SCOR indicates a corresponding change in splanchnic tissue oxygenation as the numerator, whereas cerebral tissue oxygenation as the denominator remains stable. However, it is questionable to utilise this concept to detect splanchnic oxygenation changes in the context of packed red blood cell transfusion (PRBCT). AIM: The current study examines the contribution of both cerebral and splanchnic oxygenation components to PRBCT-associated SCOR changes in preterm infants. DESIGN: Prospective cohort study. SETTING: Neonatal intensive care. PATIENTS: Hemodynamically stable infants: Gestation <32 weeks; birth weight <1500 g; postmenstrual age <37 weeks: tolerating ≥120 ml/kg/day feed volume. INTERVENTIONS: PRBCT at 15 ml/kg, over 4 h. MAIN OUTCOME MEASURES: Transfusion-associated changes were determined by performing mixed models for repeated measures analysis between the 4-h mean pre-transfusion values (SCOR 0, StO2 s 0, and StO2 c 0) and the post-transfusion hourly mean values for the next 28 h (SCOR 1-28, StO2 s 1-28, and StO2 c 1-28). Dunnett's method was used to adjust for the multiplicity of the p value. RESULTS: Of 30 enrolled infants 14 [46.7%] male; median [IQR] birth weight, 923 [655-1064] g; gestation, 26.4 [25.5-28.1] weeks; enrolment weight, 1549 [1113-1882] g; and postmenstrual age, 33.6 [32.4-35.0] weeks, one infant was excluded because of corrupted NIRS data. With the commencement of PRBCT, SCOR demonstrated a downward trend throughout the study period. This drift was associated with an increasing StO2 c trend, while StO2 s remained unchanged throughout the study period. CONCLUSIONS AND RELEVANCE: PRBCT-associated SCOR decrease suggests improvement in cerebral oxygenation rather than worsening splanchnic oxygenation. Our study underlines that it is necessary to determine individual components of SCOR, namely cerebral and splanchnic StO2 to understand SCOR changes in the context of PRBCT.

Hierarchical improvement of regional tissue oxygenation after packed red blood cell transfusion.

BACKGROUND: It is well established that counter-regulation to hypoxia follows a hierarchical pattern, with brain-sparing in preference to peripheral tissues. In contrast, it is unknown if the same hierarchical sequence applies to recovery from hypoxia after correction of anemia with packed red blood cell transfusion (PRBCT). OBJECTIVE: To understand the chronology of cerebral and splanchnic tissue oxygenation resulting after correction of anemia by PRBCT in preterm infants using near-infrared spectroscopy (NIRS). DESIGN: Prospective cohort study. SETTING: Neonatal intensive care. PATIENTS INCLUDED: Haemodynamically stable infants: <32 weeks gestation, <37weeks postmenstrual age, <1500 grams birth weight; and ≥120 mL/kg/day feeds tolerated. INTERVENTION: PRBCT at 15 mL/Kg over 4 hours. MAIN OUTCOME MEASURES: Transfusion-associated changes were determined by comparing the 4-hour mean pre-transfusion cerebral and splanchnic fractional tissue oxygen extraction (FTOEc0; FTOEs0) with hourly means during (FTOEc1-4; FTOEs1-4) and for 24 hours after PRBCT completion (FTOEc5-28; FTOEs5-28). RESULTS: Of 30 enrolled infants, 14[46.7%] male; median[IQR] birth weight, 923[655-1064]g; gestation, 26.4[25.5-28.1]weeks; enrolment weight, 1549[1113-1882]g; and postmenstrual age, 33.6[32.4-35]weeks, 1 infant was excluded because of corrupted NIRS data. FTOEc significantly decreased during and for 24 hours after PRBCT (p < 0.001), indicating prompt improvement in cerebral oxygenation. In contrast, FTOEs showed no significant changes during and after PRBCT (p>0.05), indicating failure of improvement in splanchnic oxygenation. CONCLUSION: Improvement in regional oxygenation after PRBCT follows the same hierarchical pattern with a prompt improvement of cerebral but not splanchnic tissue oxygenation. We hypothesise that this hierarchical recovery may indicate continued splanchnic hypoxia in the immediate post-transfusion period and vulnerability to transfusion-associated necrotizing enterocolitis (TANEC). Our study provides a possible mechanistic underpinning for TANEC and warrants future randomised controlled studies to stratify its prevention.

The Effect of Cigarette Smoking during Pregnancy on Endocrine Pancreatic Function and Fetal Growth: A Pilot Study.

INTRODUCTION: Cigarette smoking in pregnancy is a common cause of fetal growth restriction. We aimed to investigate endocrine pancreatic function of mother-infant dyads in relation to cigarette smoking, as a possible mechanism for the poor fetal growth. METHODS: Prospective study of smoking mothers (10 cigarettes or more per day, self-reported to the midwife) and non-smoker control mothers during their first pregnancy. Insulin, glucose, C-peptide, HbA1C, fructosamine, prolactin, serotonin, and cortisol were measured in maternal blood at 24-26 weeks and in umbilical cord blood at birth. Cotinine was also measured in cord blood. RESULTS: Of 37 smokers and 36 non-smokers recruited, cord blood was obtainable from 38 babies (19 in each group). In utero cigarette exposure was associated with lower birthweight (3,035 ± 490 versus 3,405 ± 598 g, p = 0.005), with linear modeling of the smoking cohort showing a 41 g reduction for every increase of one cigarette smoked per day (95% CI -71 to -11 g, p = 0.010). There were no differences between groups in indices of maternal or perinatal endocrine pancreatic dysfunction. Heavier smoking independently correlated with higher maternal fasting levels of glucose (p = 0.044) and C-peptide (p = 0.011). We did not observe any significant associations between the daily number of cigarettes and any of the cord blood parameters. We also looked for differences between cohorts based on infant gender. Serotonin levels were higher in smoking mothers with male fetuses (p = 0.01 to p = 0.004). CONCLUSION: Endocrine pancreatic dysfunction does not appear to be a major contributing factor to nicotine-associated fetal growth restriction. The higher serotonin levels in smoking mothers carrying male infants is of uncertain significance but could be a manifestation of gender differences in susceptibility to the long-term effects of cigarette smoking.

Spaced scenario demonstrations improve knowledge and confidence in pediatric acute illness management.

OBJECTIVES: Nationally accredited simulation courses such as advance pediatric life support and pediatric advance life support are recommended for health care professionals (HCPs) at two yearly intervals as a minimum requirement, despite literature evidence suggesting rapid decline in knowledge shortly after course completion. The objective of this study was to evaluate an observation-based, educational intervention program aimed at improving previously acquired knowledge and confidence in managing critical illnesses. METHODS: A prospective cohort longitudinal study was conducted over a 6-month period. Participants were assessed with a knowledge based questionnaire immediately prior to and after observing 12 fortnightly critical illness scenario demonstrations (CISDs). The outcome measure was performance on questionnaires. Regression analysis was used to adjust for potential confounders. Questionnaire practice effect was evaluated on 30 independent HCPs not exposed to the CISDs. RESULTS: Fifty-four HCPs (40 doctors and 14 nurses) participated in the study. All participants had previously attended nationally accredited simulation courses with a mean time since last attendance of 1.8 ± 0.4 years. The median number of attendances at CISD was 6 (2-12). The mean questionnaire scores at baseline (17.2/25) were significantly lower than the mean post intervention questionnaire scores (20.3/25), p = 0.003. The HCPs self-rated confidence in managing CISD was 6.5 times higher at the end of the program in the intervention group (p = 0.002) than at baseline. There was no practice effect for questionnaires demonstrated in the independent sample. CONCLUSION: The educational intervention program significantly improved the knowledge and confidence of the participants in managing pediatric critical illnesses. The CISD program provides an inexpensive, practical, and time effective method of facilitating knowledge acquisition and retention. Despite the distinctively different approach, this study has shown the effectiveness of the participant being an observer to enhance pediatric resuscitation skills.

Gestational Diabetes Independently Increases Birth Length and Augments the Effects of Maternal BMI on Birth Weight: A Retrospective Cohort Study.

OBJECTIVE: To investigate the effect of the interaction between gestational diabetes mellitus (GDM) and maternal body mass index (BMI) on the individual neonatal growth parameters. DESIGN: Retrospective cohort study. SETTING: A tertiary maternity service in Sydney, Australia, between 2005 and 2009. POPULATION: A cohort of 8859 women. METHODS: Generalized linear models. MAIN OUTCOME MEASURES: Neonatal growth parameters, represented by z-scores for infant birth weight (BW), birth length (BL), and head circumference (HC) in GDM and non-GDM groups. RESULTS: Only GDM alone had an independent and positive effect on BL (p = 0.02) but not on BW or HC. In addition, in pregnancies complicated with GDM, the association between maternal weight and BW was significantly stronger (p < 0.001). In combination, GDM and maternal BMI significantly affected z-score differences between BW and BL (p < 0.001), in that underweight mothers had babies that were lighter relative to their length and inversely obese mothers had babies that were heavier relative to their length. CONCLUSION: GDM independently influences BL and increases the association between maternal BMI and BW. In accordance with the hypothesis of the fetal origins of health and disease, the pronounced effects of GDM on fetal growth patterns demonstrated in this study are likely to influence long-term health outcomes in children.

Innate and adaptive immune interactions at the fetal-maternal interface in healthy human pregnancy and pre-eclampsia.

Maternal immune tolerance of the fetus is indispensable for a healthy pregnancy outcome. Nowhere is this immune tolerance more important than at the fetal-maternal interface - the decidua, the site of implantation, and placentation. Indeed, many lines of evidence suggest an immunological origin to the common pregnancy-related disorder, pre-eclampsia. Within the innate immune system, decidual NK cells and antigen presenting cells (including dendritic cells and macrophages) make up a large proportion of the decidual leukocyte population, and are thought to modulate vascular remodeling and trophoblast invasion. On the other hand, within the adaptive immune system, Foxp3(+) regulatory T cells are crucial for ensuring immune tolerance toward the semi-allogeneic fetus. Additionally, another population of CD4(+)HLA-G(+) suppressor T cells has also been identified as a potential player in the maintenance of immune tolerance. More recently, studies are beginning to unravel the potential interactions between the innate and the adaptive immune system within the decidua, that are required to maintain a healthy pregnancy. In this review, we discuss the recent advances exploring the complex crosstalk between the innate and the adaptive immune system during human pregnancy.

A case of periodic fever and persistent splenomegaly in a 2-year-old boy.

We report an unusual case of periodic fever associated with persistent splenomegaly in a 2-year-old boy. Febrile episodes occurred at regular 2 weekly intervals and each lasted for 1-2 days. Following resolution of the fever on each occasion, the patient developed neck stiffness of 1-2 days duration. The periodic febrile episodes, as well as the splenomegaly, spontaneously resolved 9 months after the onset of disease. Infectious and malignant causes were ruled out as far as possible. This patient's clinical features are unusual and do not match any known category of periodic fevers in childhood. We believe this case highlights the diagnostic challenges periodic fevers commonly represent.