The Adipose Organ Is a Unitary Structure in Mice and Humans.

Obesity is the fifth leading cause of death worldwide. In mice and humans with obesity, the adipose organ undergoes remarkable morpho-functional alterations. The comprehension of the adipose organ function and organization is of paramount importance to understand its pathology and formulate future therapeutic strategies. In the present study, we performed anatomical dissections, magnetic resonance imaging, computed axial tomography and histological and immunohistochemical assessments of humans and mouse adipose tissues. We demonstrate that most of the two types of adipose tissues (white, WAT and brown, BAT) form a large unitary structure fulfilling all the requirements necessary to be considered as a true organ in both species. A detailed analysis of the gross anatomy of mouse adipose organs in different pathophysiological conditions (normal, cold, pregnancy, obesity) shows that the organ consists of a unitary structure composed of different tissues: WAT, BAT, and glands (pregnancy). Data from autoptic dissection of 8 cadavers, 2 females and 6 males (Age: 37.5 ± 9.7, BMI: 23 ± 2.7 kg/m2) and from detailed digital dissection of 4 digitalized cadavers, 2 females and 2 males (Age: 39 ± 14.2 years, BMI: 22.8 ± 4.3 kg/m2) confirmed the mixed (WAT and BAT) composition and the unitary structure of the adipose organ also in humans. Considering the remarkable endocrine roles of WAT and BAT, the definition of the endocrine adipose organ would be even more appropriate in mice and humans.

Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review.

Delirium is one of the most commonly occurring postoperative complications in older adults. It occurs due to the vulnerability of cerebral functioning to pathophysiological stressors. Identification of those at increased risk of developing delirium early in the surgical pathway provides an opportunity for modification of predisposing and precipitating risk factors and effective shared decision-making. No single delirium prediction tool is used widely in surgical settings. Multi-component interventions to prevent delirium involve structured risk factor modification supported by geriatrician input; these are clinically efficacious and cost effective. Barriers to the widespread implementation of such complex interventions exist, resulting in an 'implementation gap'. There is a lack of evidence for pharmacological prophylaxis for the prevention of delirium. Current evidence suggests that avoidance of peri-operative benzodiazepines, careful titration of anaesthetic depth guided by processed electroencephalogram monitoring and treatment of pain are the most effective strategies to minimise the risk of delirium. Addressing postoperative delirium requires a collaborative, whole pathway approach, beginning with the early identification of those patients who are at risk. The research agenda should continue to examine the potential for pharmacological prophylaxis to prevent delirium while also addressing how successful models of delirium prevention can be translated from one setting to another, underpinned by implementation science methodology.

The use of portable XRF as a forensic geoscience non-destructive trace evidence tool for environmental and criminal investigations.

Hand-held, portable X-Ray fluorescence instruments (pXRF) provide a means of rapid, in-situ chemical characterisation that has considerable application as a rapid trace evidence characterisation tool in forensic geoscience. This study presents both a control test study which demonstrates optimisation of the data collection process, alongside a range of individual forensic case studies, including heavy metal contamination, conflict archaeology, forensic soil characterisation, and verification of human remains, which together validate the technique and provide some comparison between field-based and laboratory-based pXRF applications. Results highlight the time-efficiency and cost-effectiveness of in-situ, field-based pXRF analyses for material characterisation when compared with other trace evidence methods. Analytical precision of various analytes during in-situ analysis was sufficient to demonstrate considerable application of field-based pXRF as a tool for rapid identification of specific areas of interest to be further investigated. Laboratory-based pXRF analyses yielded greater accuracy which could provide an efficient compromise between field-based pXRF and traditional laboratory-based analytical techniques (e.g. WD-XRF, ICP-MS). Further studies should collect more advanced datasets in more diverse locations to further validate the techniques capability to rapidly conduct geochemical surveys in a range of environments.

Early Magnetic Resonance Imaging Predicts 30-Month Outcomes after Therapeutic Hypothermia for Neonatal Encephalopathy.

OBJECTIVE: To evaluate the association of therapeutic hypothermia with magnetic resonance imaging (MRI) findings and 30-month neurodevelopment in term neonatal encephalopathy. STUDY DESIGN: Cross-sectional analysis of 30-month neurodevelopment (IQR 19.0-31.4) in a prospective cohort of mild-to-severe neonatal encephalopathy imaged on day 4 (1993-2017 with institutional implementation of therapeutic hypothermia in 2007). MRI injury was classified as normal, watershed, or basal ganglia/thalamus. Abnormal motor outcome was defined as Bayley-II psychomotor developmental index <70, Bayley-III motor score <85 or functional motor deficit. Abnormal cognitive outcome was defined as Bayley-II mental developmental index <70 or Bayley-III cognitive score <85. Abnormal composite outcome was defined as abnormal motor and/or cognitive outcome, or death. The association of therapeutic hypothermia with MRI and outcomes was evaluated with multivariable logistic regression adjusted for propensity to receive therapeutic hypothermia. RESULTS: Follow-up was available in 317 (78%) surviving children, of whom 155 (49%) received therapeutic hypothermia. Adjusting for propensity, therapeutic hypothermia was independently associated with decreased odds of abnormal motor (OR 0.15, 95% CI 0.06-0.40, P < .001) and cognitive (OR 0.11, 95% CI 0.04-0.33, P < .001) outcomes. This association remained statistically significant after adjustment for injury pattern. The predictive accuracy of MRI pattern for abnormal composite outcome was unchanged between therapeutic hypothermia-treated (area under the receiver operating curve 0.76; 95% CI 0.61-0.91) and untreated (area under the receiver operating curve 0.74; 95% CI 0.67-0.81) infants. The negative predictive value of normal MRI was high in therapeutic hypothermia-treated and untreated infants (motor 96% vs 90%; cognitive 99% vs 95%). CONCLUSIONS: Therapeutic hypothermia is associated with lower rates of brain injury and adverse 30-month outcomes after neonatal encephalopathy. The predictive accuracy of MRI in the first week of life is unchanged by therapeutic hypothermia. Normal MRI remains reassuring for normal 30-month outcome after therapeutic hypothermia.

Bronchopulmonary dysplasia precursors influence risk of white matter injury and adverse neurodevelopmental outcome in preterm infants.

BACKGROUND: Cumulative supplemental oxygen (CSO) and cumulative mean airway pressure (CMAP) are associated with bronchopulmonary dysplasia (BPD) in preterm infants, but their relationships to white matter injury (WMI) and neurodevelopment have not been evaluated. METHODS: Preterm infants <32 weeks' gestation were prospectively imaged with 3 T MRI near term. CSO and CMAP were retrospectively summed over the first 14 and 28 days. Neurodevelopment was assessed at 30 months adjusted using the Bayley-III. ROC and linear regression were used to evaluate the relationship between CSO, CMAP, and BPD with WMI and neurodevelopmental performance, respectively. RESULTS: Of the 87 infants, 30 (34.5%) had moderate-severe BPD, which was associated with WMI (OR 5.5, 95% CI 1.1-34.9, p = 0.012). CSO and CMAP predicted WMI as well as BPD (AUC 0.68-0.77). CSO was independently associated with decreased language and cognitive performance (mean difference at 14 days: -11.0, 95% CI -19.8 to -2.2, p = 0.015 and -9.8, 95% CI -18.9 to -0.7, p = 0.035, respectively) at 30 months adjusted. CONCLUSIONS: BPD precursors predict WMI as well as BPD. Cumulative supplemental oxygen over the first 14 days of life is independently associated with lower language and cognitive performances. These data suggest that early respiratory status influences the risk of adverse neurodevelopment in preterm infants. IMPACT: Respiratory precursors to bronchopulmonary dysplasia (BPD), cumulative supplemental oxygen and mean airway pressure, over the first 14-28 days performed as well as BPD for the prediction of white matter injury on MRI in preterm infants. Cumulative supplemental oxygen was independently associated with lower language and cognitive performance on the Bayley-III at 30 months adjusted. These data suggest that early respiratory status may help explain why BPD is independently associated with adverse neurodevelopmental outcomes in the preterm population and highlights the importance of interventions targeting respiratory status as a potential avenue to improve neurodevelopmental outcomes.

Newborn metabolic vulnerability profile identifies preterm infants at risk for mortality and morbidity.

BACKGROUND: Identifying preterm infants at risk for mortality or major morbidity traditionally relies on gestational age, birth weight, and other clinical characteristics that offer underwhelming utility. We sought to determine whether a newborn metabolic vulnerability profile at birth can be used to evaluate risk for neonatal mortality and major morbidity in preterm infants. METHODS: This was a population-based retrospective cohort study of preterm infants born between 2005 and 2011 in California. We created a newborn metabolic vulnerability profile wherein maternal/infant characteristics along with routine newborn screening metabolites were evaluated for their association with neonatal mortality or major morbidity. RESULTS: Nine thousand six hundred and thirty-nine (9.2%) preterm infants experienced mortality or at least one complication. Six characteristics and 19 metabolites were included in the final metabolic vulnerability model. The model demonstrated exceptional performance for the composite outcome of mortality or any major morbidity (AUC 0.923 (95% CI: 0.917-0.929). Performance was maintained across mortality and morbidity subgroups (AUCs 0.893-0.979). CONCLUSIONS: Metabolites measured as part of routine newborn screening can be used to create a metabolic vulnerability profile. These findings lay the foundation for targeted clinical monitoring and further investigation of biological pathways that may increase the risk of neonatal death or major complications in infants born preterm. IMPACT: We built a newborn metabolic vulnerability profile that could identify preterm infants at risk for major morbidity and mortality. Identifying high-risk infants by this method is novel to the field and outperforms models currently in use that rely primarily on infant characteristics. Utilizing the newborn metabolic vulnerability profile for precision clinical monitoring and targeted investigation of etiologic pathways could lead to reductions in the incidence and severity of major morbidities associated with preterm birth.

The emerging specialty of perioperative medicine: a UK survey of the attitudes and behaviours of anaesthetists.

BACKGROUND: In 2014, the Royal College of Anaesthetists (RCoA) launched the Perioperative Medicine Programme to facilitate the delivery of best preoperative, intraoperative and postoperative care through implementation of evidence-based medicine to reduce variation and improve postoperative outcomes. However, variation exists in the establishment of perioperative medicine services in the UK. This survey explored attitudes and behaviours of anaesthetists towards perioperative medicine, described current anaesthetic-led perioperative medicine services across the UK and explored barriers to anaesthetic involvement in perioperative medicine. METHODS: Survey content based on the RCoA vision document was refined and validated using an expert panel. An anonymous electronic survey was then sent by email to the members of the RCoA. RESULTS: Seven hundred fifty-eight UK anaesthetists (4.5% of the RCoA mailing list) responded to the survey. Of these, 64% considered themselves a perioperative doctor, with 65% having changed local services in response to the RCoA vision. Barriers to developing perioperative medicine included insufficient time (75%) and inadequate training (51%). Three quarters of respondents advocate anaesthetists leading the development of perioperative medicine. CONCLUSIONS: Despite evidence of emerging services, this survey describes barriers to ongoing development of perioperative medicine. Facilitators may include increased clinical exposure, targeted education and training and collaborative working with other specialties.

The older surgical patient - to operate or not? A state of the art review.

The increasing age and subsequent medical complexity of patients presenting for surgery grants the opportunity to examine the processes and delivery of peri-operative care. There is a need to redesign peri-operative pathways allowing room for shared decision making and personalised, evidence-based care. In times of financial constraint, this is no easy task. However, neglecting to transform services now may lead to challenges in the sustainability of the provision of peri-operative care in the long-term. Challenges in redesigning peri-operative care pathways include identification and optimisation of those at highest peri-operative risk to inform the difficult conversations surrounding the appropriateness of surgery. The moral burden of these conversations on patient and professionals alike is increasingly recognised and managing this issue requires innovative models of collaborative, multidisciplinary and interprofessional working. To operate or not can be a challenging question to answer with a number of different perspectives to consider; not least that of the patient.

Observations on the retina and 'optical fold' of a mesopelagic sabretooth fish, Evermanella balbo.

The 'optical fold' of Evermanella balbo covers the ventro-lateral cornea and is presumed to capture illumination that would otherwise remain undetected by the tubular eye of this mesopelagic teleost. It contains alternating bands of cellular and acellular material, running approximately perpendicular to the lateral surface of the eye. Only parts of this lamellar body lie within the eyelid-like structure. The cellular lamellae are 2-2.5 µm thick centrally and composed of fibroblast-like cells. The extracellular bands (4.5-5 µm thick) contain regular arrays of collagen fibrils, with layers of thin fibrils sandwiching a region of thicker fibrils. The thin fibrils are organised in alternating sheets where fibrils, although all parallel, change their orientation by 90° between each sheet. All thick fibrils are oriented parallel to the lateral surface of the 'optical fold'. In the main retina, small bundles of rod inner/outer segments are separated by the processes of the retinal pigment epithelium (rpe) laterally. Centrally, the length of tightly packed rods increases, but rpe processes no longer divide them into bundles. Medially, rod length increases further, but packing is less dense. The accessory retina is significantly thinner, and less well-developed than the main retina. Ventrally, the rods show no regular arrangement and are not grouped. Dorsally, however, rods are arranged into bundles, separated by melanosome-filled rpe processes. The thickness of the retina increases as it approaches the crystalline lens. It is on this dorsal accessory retina that light traversing the 'optical fold' most likely falls, facilitating the detection of moving objects in the ventro-lateral field of view.

Sensory gating in bilayer amorphous carbon memristors.

Multi-state amorphous carbon-based memory devices have been developed that exhibit both bipolar and unipolar resistive switching behaviour. These modes of operation were implemented independently to access multiple resistance states, enabling higher memory density than conventional binary non-volatile memory technologies. The switching characteristics have been further utilised to study synaptic computational functions that could be implemented in artificial neural networks. Notably, paired-pulse inhibition (PPI) is observed at bio-realistic timescales (<100 ms). Devices displaying this rich synaptic behaviour could function as robust stand-alone synapse-inspired memory or be applied as filters for specialised neuromorphic circuits and sensors.

Fish associated with a subsea pipeline and adjacent seafloor of the North West Shelf of Western Australia.

Information on the potential ecological value of offshore oil and gas infrastructure is required as it reaches the end of its operational life and decisions must be made regarding the best practice option for decommissioning. This study uses baited remote underwater stereo-video systems to assess fish assemblages along an offshore subsea pipeline and in adjacent natural seabed habitats at ∼140 m depth on the North West Shelf of Western Australia. A total of 955 fish from 40 species and 25 families were recorded. Species richness was, on average 25% higher on the pipeline (6.48 ±â€¯0.37 SE) than off (4.81 ±â€¯0.28 SE) while relative abundance of fish was nearly double on the pipeline (20.38 ±â€¯2.81 SE) than in adjacent natural habitats (10.97 ±â€¯1.02 SE). The pipeline was characterised by large, commercially important species known to associate with complex epibenthic habitat and, as such, possessed a biomass of commercial fish ca 7.5 × higher and catch value ca. 8.6 × ($65.11 ±â€¯$11.14 SE) than in adjacent natural habitats ($7.57 ±â€¯$2.41 SE). This study has added to the knowledge of fish assemblage associations with subsea infrastructure and provides a greater understanding of the ecological and fisheries implications of decommissioning, helping to better inform decision-making on the fate of infrastructure.

A Foundation Programme educational placement in peri-operative medicine for older people: mixed methods evaluation.

We established an innovative Foundation placement in peri-operative medicine for older patients in response to the need for training in 'whole patient' medicine and the challenge of fewer Foundation doctors in acute surgical roles. The placement and underpinning curriculum were co-designed with junior doctors and other clinical stakeholders. This resulted in a modular design offering acute and community experience and dedicated quality improvement project time. To evaluate the placement we used a mixed methods study based on Kirkpatrick's model of workplace learning. Level 1 (trainee reaction) was evaluated using Job Evaluation Study Tool questionnaires and nominal group technique. Levels 2 and 3 (trainee learning/behaviour) were assessed using a Likert-style survey mapped to curriculum objectives, e-portfolio completion, nominal group technique and documentation of completed quality improvement projects and oral/poster presentations. Sixty-eight foundation trainees underwent the new placement. A similar-sized 'control' sample (n = 57) of surgical Foundation trainees within the same Trust was recruited. The trainees in the peri-operative placement attained both generic Foundation and specific peri-operative curriculum competencies, and gave higher job satisfaction scores than trainees in standard surgical placements. The top three ranked advantages from the nominal group sessions were senior support, clinical variety and project opportunities. Universal project completion resulted in high rates of poster and platform presentations, and in sustained service changes at hospital level.

Initial Metabolic Profiles Are Associated with 7-Day Survival among Infants Born at 22-25 Weeks of Gestation.

OBJECTIVE: To evaluate the association between early metabolic profiles combined with infant characteristics and survival past 7 days of age in infants born at 22-25 weeks of gestation. STUDY DESIGN: This nested case-control consisted of 465 singleton live births in California from 2005 to 2011 at 22-25 weeks of gestation. All infants had newborn metabolic screening data available. Data included linked birth certificate and mother and infant hospital discharge records. Mortality was derived from linked death certificates and death discharge information. Each death within 7 days was matched to 4 surviving controls by gestational age and birth weight z score category, leaving 93 cases and 372 controls. The association between explanatory variables and 7-day survival was modeled via stepwise logistic regression. Infant characteristics, 42 metabolites, and 12 metabolite ratios were considered for model inclusion. Model performance was assessed via area under the curve. RESULTS: The final model included 1 characteristic and 11 metabolites. The model demonstrated a strong association between metabolic patterns and infant survival (area under the curve [AUC] 0.885, 95% CI 0.851-0.920). Furthermore, a model with just the selected metabolites performed better (AUC 0.879, 95% CI 0.841-0.916) than a model with multiple clinical characteristics (AUC 0.685, 95% CI 0.627-0.742). CONCLUSIONS: Use of metabolomics significantly strengthens the association with 7-day survival in infants born extremely premature. Physicians may be able to use metabolic profiles at birth to refine mortality risks and inform postnatal counseling for infants born at <26 weeks of gestation.

Racial and Ethnic Disparities in Preterm Infant Mortality and Severe Morbidity: A Population-Based Study.

BACKGROUND: Disparities exist in the rates of preterm birth and infant mortality across different racial/ethnic groups. However, only a few studies have examined the impact of race/ethnicity on the outcomes of premature infants. OBJECTIVE: To report the rates of mortality and severe neonatal morbidity among multiple gestational age (GA) groups stratified by race/ethnicity. METHODS: A retrospective cohort study utilizing linked birth certificate, hospital discharge, readmission, and death records up to 1 year of life. Live-born infants ≤36 weeks born in the period 2007-2012 were included. Maternal self-identified race/ethnicity, as recorded on the birth certificate, was used. ICD-9 diagnostic and procedure codes captured neonatal morbidities (intraventricular hemorrhage, retinopathy of prematurity, periventricular leukomalacia, bronchopulmonary dysplasia, and necrotizing enterocolitis). Multiple logistic regression was performed to evaluate the impact of race/ethnicity on mortality and morbidity, adjusting for GA, birth weight, sex, and multiple gestation. RESULTS: Our cohort totaled 245,242 preterm infants; 26% were white, 46% Hispanic, 8% black, and 12% Asian. At 22-25 weeks, black infants were less likely to die than white infants (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.62-0.94). However, black infants born at 32-34 weeks (OR 1.64; 95% CI 1.15-2.32) or 35-36 weeks (OR 1.57; 95% CI 1.00-2.24) were more likely to die. Hispanic infants born at 35-36 weeks were less likely to die than white infants (OR 0.66; 95% CI 0.50-0.87). Racial disparities at different GAs were also detected for severe morbidities. CONCLUSIONS: The impact of race/ethnicity on mortality and severe morbidity varied across GA categories in preterm infants. Disparities persisted even after adjusting for important potential confounders.

Referral patterns, delays, and equity in access to advanced paediatric emergency care in Vietnam.

BACKGROUND: Quality emergency care is a critical component of a well-functioning health system. However, severely ill children often face barriers to timely, appropriate care in less-developed health systems. Such barriers disproportionately affect poorer children, and may be particularly acute when children seek advanced emergency care. We examine predictors of increased acuity and patient outcomes at a tertiary paediatric emergency department to identify barriers to advanced emergency care among children. METHODS: We analysed a sample of 557 children admitted to a paediatric referral hospital in Hanoi, Vietnam. We examined associations between socio-demographic and facility characteristics, referrals and transfers, and patient outcomes. We used generalized ordered logistic regression to examine predictors of increased acuity on arrival. RESULTS: Most children accessing advanced emergency care were under two years of age (68.4%). Pneumonia was the most prevalent diagnosis (23.7%). Children referred from lower-level facilities experienced higher acuity on arrival (p = .000), were more likely to be admitted to an ICU (p = .000), and were more likely to die during hospitalization (p = .009). The poorest children [OR = 4.98, (1.82-13.61)], and children entering care at provincial hospitals [OR = 3.66, (2.39-5.63)] and other lower-level facilities [OR = 3.24, (1.78-5.88)] had significantly higher odds of increased acuity on arrival. CONCLUSIONS: The poorest children, who were more likely to enter care at lower-level facilities, were especially disadvantaged. While delays in entry to care were not predictive of acuity, children referred to tertiary care from lower-level facilities experienced worse outcomes. Improvements in triage, stabilization, and referral linkages at all levels should reduce within-system delays, increasing timely access to advanced emergency care for all children.

The effects of surface structure mutations in Arabidopsis thaliana on the polarization of reflections from virus-infected leaves.

The way in which light is polarized when reflected from leaves can be affected by infection with plant viruses. This has the potential to influence viral transmission by insect vectors due to altered visual attractiveness of infected plants. The optical and topological properties of cuticular waxes and trichomes are important determinants of how light is polarized upon reflection. Changes in expression of genes involved in the formation of surface structures have also been reported following viral infection. This paper investigates the role of altered surface structures in virus-induced changes to polarization reflection from leaves. The percentage polarization of reflections from Arabidopsis thaliana cer5, cer6 and cer8 wax synthesis mutants, and the gl1 leaf hair mutant, was compared to those from wild-type (WT) leaves. The cer5 mutant leaves were less polarizing than WT on the adaxial and abaxial surfaces; gl1 leaves were more polarizing than WT on the adaxial surfaces. The cer6 and cer8 mutations did not significantly affect polarization reflection. The impacts of Turnip vein clearing virus (TVCV) infection on the polarization of reflected light were significantly affected by cer5 mutation, with the reflections from cer5 mutants being higher than those from WT leaves, suggesting that changes in CER5 expression following infection could influence the polarization of the reflections. There was, however, no significant effect of the gl1 mutation on polarization following TVCV infection. The cer5 and gl1 mutations did not affect the changes in polarization following Cucumber mosaic virus (CMV) infection. The accumulation of TVCV and CMV did not differ significantly between mutant and WT leaves, suggesting that altered expression of surface structure genes does not significantly affect viral titres, raising the possibility that if such regulatory changes have any adaptive value it may possibly be through impacts on viral transmission.

Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery.

BACKGROUND: Increasing numbers of older patients are undergoing vascular surgery. Inadequate preoperative assessment and optimization may contribute to increased postoperative morbidity and mortality. METHODS: Patients aged at least 65 years scheduled for elective aortic aneurysm repair or lower-limb arterial surgery were enrolled in an RCT of standard preoperative assessment or preoperative comprehensive geriatric assessment and optimization. Randomization was stratified by sex and surgical site (aorta/lower limb). Primary outcome was length of hospital stay. Secondary outcome measures included new medical co-morbidities, postoperative medical or surgical complications, discharge to a higher level of dependency and 30-day readmission rate. RESULTS: A total of 176 patients were included in the final analysis (control 91, intervention 85). Geometric mean length of stay was 5·53 days in the control group and 3·32 days in the intervention group (ratio of geometric means 0·60, 95 per cent c.i. 0·46 to 0·79; P < 0·001). There was a lower incidence of delirium (11 versus 24 per cent; P = 0·018), cardiac complications (8 versus 27 per cent; P = 0·001) and bladder/bowel complications (33 versus 55 per cent; P = 0·003) in the intervention group compared with the control group. Patients in the intervention group were less likely to require discharge to a higher level of dependency (4 of 85 versus 12 of 91; P = 0·051). CONCLUSION: In this study of patients aged 65 years or older undergoing vascular surgery, preoperative comprehensive geriatric assessment was associated with a shorter length of hospital stay. Patients undergoing assessment and optimization had a lower incidence of complications and were less likely to be discharged to a higher level of dependency. Registration number: ISRCTN23142588 (http://www.controlled-trials.com).

Dynamic outcome prediction in a socio-demographically diverse population-based cohort of extremely preterm neonates.

OBJECTIVE: Accurate outcome prediction is crucial for counseling parents and providing individualized treatment to extremely premature infants. We sought to improve upon existing prediction model by using a diverse population-based cohort of extremely premature live births (⩽28 weeks' gestation) for survival and survival without severe neonatal morbidity at different times throughout the first week of life and to evaluate potential differences by race/ethnicity and maternal education. STUDY DESIGN: Retrospective cohort study of all California live births from 2007 through 2011 with linked birth, death and hospital discharge records. RESULTS: A total of 6009 infants were included. In the validation data set at time of delivery, the area under the receiver-operating characteristic curve for the model containing all predictors was 0.863 for survival and 0.789 for survival without severe morbidity. The marginal probability of survival without severe neonatal morbidity of an Asian infant born to a mother with <12 years of education compared with the reference (Caucasian infant, mother with ⩾12 years of education) was -0.23 (95% confidence interval (CI) -0.31 to -0.15) for all infants at time of birth and -0.28 (95% CI -0.39 to -0.18) for infants with attempted resuscitation. Notably, no other differences by racial/ethnic category and maternal education emerged. CONCLUSIONS: Probabilities of survival and survival without major morbidity change rapidly throughout the first week of life. Extremely premature infants born to Asian mothers with less than a high school education appear to have a lower probability to survive without significant morbidity compared with their Caucasian peers.

Persistent Pulmonary Hypertension of the Newborn in Late Preterm and Term Infants in California.

BACKGROUND AND OBJECTIVES: There are limited epidemiologic data on persistent pulmonary hypertension of the newborn (PPHN). We sought to describe the incidence and 1-year mortality of PPHN by its underlying cause, and to identify risk factors for PPHN in a contemporary population-based dataset. METHODS: The California Office of Statewide Health Planning and Development maintains a database linking maternal and infant hospital discharges, readmissions, and birth and death certificates from 1 year before to 1 year after birth. We searched the database (2007-2011) for cases of PPHN (identified by International Classification of Diseases, Ninth Revision codes), including infants ≥34 weeks' gestational age without congenital heart disease. Multivariate Poisson regression was used to identify risk factors associated with PPHN; results are presented as risk ratios, 95% confidence intervals. RESULTS: Incidence of PPHN was 0.18% (3277 cases/1 781 156 live births). Infection was the most common cause (30.0%). One-year mortality was 7.6%; infants with congenital anomalies of the respiratory tract had the highest mortality (32.0%). Risk factors independently associated with PPHN included gestational age <37 weeks, black race, large and small for gestational age, maternal preexisting and gestational diabetes, obesity, and advanced age. Female sex, Hispanic ethnicity, and multiple gestation were protective against PPHN. CONCLUSIONS: This risk factor profile will aid clinicians identifying infants at increased risk for PPHN, as they are at greater risk for rapid clinical deterioration.