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To estimate the risk of magnetic resonance imaging (MRI)-based structural changes in knee osteoarthritis (OA) among individuals with meniscal tear and knee OA, using MRIs obtained at baseline and 18 and 60 months after randomization in a randomized controlled trial of arthroscopic partial meniscectomy (APM) versus physical therapy (PT).We used data from the Meniscal Tear in Osteoarthritis Research (METEOR) trial. MRIs were read using the MRI OA Knee Score (MOAKS). We used linear mixed-effects models to examine the association between treatment group and continuous MOAKS summary scores, and Poisson regression to assess categorical changes in knee joint structure. Analyses assessed changes in OA between baseline and month 18 and between months 18 and 60. We performed both intention-to-treat and as-treated analyses.The analytic sample included 302 participants. For both treatment groups, more OA changes were seen during the early interval than during the later interval. ITT analysis revealed that, between baseline and month 18, APM was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint subregions (risk ratio [RR] 1.35 [95% confidence interval (95% CI) 1.14, 1.61]) and the number of subregions damaged (RR 1.44 [95% CI 1.13, 1.85]) having a worsening effusion-synovitis score (RR 2.62 [95% CI 1.32, 5.21]), and having ≥1 additional subregion with osteophytes (RR 1.24 [95% CI 1.02, 1.50]). Significant associations were detected between months 18 and 60 only for having any subregion with a worsening osteophyte score (RR 1.28 [95% CI 1.04, 1.58]).These findings suggest that the association between APM and MRI-based structural changes in knee OA is most apparent during the initial 18 months after surgery. The reason for attenuation of this association over longer follow-up merits further investigation.

Background The main pathophysiologic characteristic of chronic respiratory disease following extremely premature birth is arrested alveolar growth, which translates to a smaller alveolar surface area (SA). We aimed to use non-invasive measurements to estimate the SA in extremely preterm infants. Methods Paired measurements of the fraction of inspired oxygen and transcutaneous oxygen saturation were used to calculate the ventilation/perfusion ratio, which was translated to SA using Fick’s law of diffusion. The SA was then adjusted using volumetric capnography. Results Thirty infants with a median (range) gestational age of 26.3 (22.9–27.9) weeks were studied. The median (range) adjusted SA was 647.9 (316.4–902.7) cm2. The adjusted SA was lower in the infants who required home oxygen [637.7 (323.5–837.5) cm2] compared to those who did not [799.1 (444.2–902.7) cm2, p = 0.016]. In predicting the need for supplemental home oxygen, the adjusted SA had an area under the receiver operator characteristic curve of 0.815 (p = 0.017). An adjusted SA ≥688.6 cm2 had 86% sensitivity and 77% specificity in predicting the need for supplemental home oxygen. Conclusions The alveolar surface area can be estimated non-invasively in extremely preterm infants. The adjusted alveolar surface area has the potential to predict the subsequent need for discharge home on supplemental oxygen. Impact We describe a novel biomarker of respiratory disease following extremely preterm birth. The adjusted alveolar surface area index was derived by non-invasive measurements of the ventilation/perfusion ratio and adjusted by concurrent measurements of volumetric capnography. The adjusted alveolar surface area was markedly reduced in extremely preterm infants studied at 7 days of life and could predict the need for discharge home on supplemental oxygen. This method could be used at the bedside to estimate the alveolar surface area and provide an index of the severity of lung disease, and assist in monitoring, clinical management and prognosis.

Objectives A greater proportion of non-pregnant smokers attempted to stop smoking during compared to before the COVID-19 pandemic. The objective of this study was to determine if a greater proportion of pregnant women also attempted to stop smoking during the pandemic rather than before. Methods The use of antenatal smoking cessation services and nicotine replacement therapies (NRT) in pregnant women was audited before (2019–2020) and during the COVID pandemic (2020–2021). Anonymised data from January 2019 to March 2021 were analysed from the Lambeth and Southwark smoking cessation service. Results A total of 252 pregnant women who smoked were referred to their local antenatal smoking cessation service, of which 90 (35.7%) (median age: 31 years [19–52 years]) chose to attend smoking cessation clinics. The COVID-19 pandemic was not associated with an increase in the number of women attending smoking cessation clinics, (2020–2021 n=46 [40.8%] of 110); compared to (2019–2020 n=44 [30.9%] of 142 referred pregnant women pre-pandemic) p=0.061. Eighty-two women utilised NRT to help them stop smoking and the frequency of NRT use did not change during the pandemic (2019–2020 n=39, 2020–2021 n=43; p=0.420). No significant difference in smoking cessation rates between the two periods was observed at either the four-week (p=0.285) or twelve-week follow-up (p=0.829). Conclusions Smoking cessation rates in pregnant women and the demand for antenatal smoking cessation services was unchanged during compared to before the COVID-19 pandemic.

Background Premature attempts at extubation and prolonged episodes of ventilatory support in preterm infants have adverse outcomes. The aim of this study was to determine whether measuring the electrical activity of the diaphragm during a spontaneous breathing trial (SBT) could predict extubation failure in preterm infants. Methods When infants were ready for extubation, the electrical activity of the diaphragm was measured by transcutaneous electromyography (EMG) before and during a SBT when the infants were on endotracheal continuous positive airway pressure. Results Forty-eight infants were recruited (median (IQR) gestational age of 27.2 (25.6–30.4) weeks). Three infants did not pass the SBT and 13 failed extubation. The amplitude of the EMG increased during the SBT [2.3 (1.5–4.2) versus 3.5 (2.1–5.3) µV; p Conclusions In all preterm infants, PMA was the strongest predictor of extubation failure; in those born Impact Composite assessments of readiness for extubation may be beneficial in the preterm population. Diaphragmatic electromyography measured by surface electrodes is a non-invasive technique to assess the electrical activity of the diaphragm. Postmenstrual age was the strongest predictor of extubation outcome in preterm infants. The change in diaphragmatic activity during a spontaneous breathing trial in extremely prematurely born infants can predict subsequent extubation failure with moderate sensitivity and specificity.

Congenital diaphragmatic hernia (CDH) results in varying degrees of pulmonary hypoplasia. Volume targeted ventilation (VTV) is a lung protective strategy but the optimal target tidal volume in CDH infants has not previously been studied. The aim of this study was to test the hypothesis that low targeted volumes would be better in CDH infants as determined by measuring the work of breathing (WOB) in CDH infants, at three different targeted tidal volumes. A randomised cross-over study was undertaken. Infants were eligible for inclusion in the study after surgical repair of their diaphragmatic defect. Targeted tidal volumes of 4, 5, and 6 ml/kg were each delivered in random order for 20-min periods with 20-min periods of baseline ventilation between. WOB was assessed and measured by using the pressure–time product of the diaphragm (PTPdi). Nine infants with a median gestational age at birth of 38 + 4 (range 36 + 4–40 + 6) weeks and median birth weight 3202 (range 2855–3800) g were studied. The PTPdi was higher at 4 ml/kg than at both 5, p = 0.008, and 6 ml/kg, p = 0.012.Conclusion: VTV of 4 ml/kg demonstrated an increased PTPdi compared to other VTV levels studied and should be avoided in post-surgical CDH infants. What is Known:• Lung injury secondary to mechanical ventilation increases the mortality and morbidity of infants with CDH.• Volume targeted ventilation (VTV) reduces ‘volutrauma’ and ventilator-induced lung injury in other neonatal intensive care populations. What is New:• A randomised cross-over trial was carried out investigating the response to different VTV levels in infants with CDH.• Despite pulmonary hypoplasia being a common finding in CDH, a VTV of 5ml/kg significantly reduced the work of breathing in infants with CDH compared to a lower VTV level.

Objective Several current and many emerging osteoarthritis (OA) treatments are intra-articular (IA) injections. However, little is known about physicians' perceptions and beliefs regarding IA injections or their considerations when deciding whether to recommend them to patients. We aimed to investigate physician-perceived benefits and drawbacks of offering IA injections. Methods We conducted individual interviews with orthopedic surgeons, rheumatologists, and physiatrists who treat patients with knee OA. We conducted a thematic analysis to identify factors that physicians weigh when making IA injection recommendations. Results We interviewed 18 physicians from academic and community practices. We identified four categories of themes that influenced providers' recommendations to their patients regarding injections: 1) the physician's knowledge, beliefs, and concerns, including their propensity to rely on guidelines versus clinical experience, and understanding of the efficacy and risks associated with injectables, such as possible cartilage damage; 2) the characteristics of the injectable product, such as ease or number of administrations needed; 3) individual patient-specific factors, including OA severity, comorbidities, and patient preference for and expectations of specific IA injections; and 4) financial and administrative factors, including insurance coverage and out-of-pocket costs. Conclusion Physicians factor the uncertain efficacy of injectable treatments and the need to manage patient expectations into their decision to offer IA therapies. Some providers relied on evidence and guidelines while others were swayed more by clinical experience. High out-of-pocket costs were seen as a barrier to use. These findings may help in the delivery of IA injections for OA and in development of injectable products.

Objective Intra-articular (IA) injections are used frequently for knee osteoarthritis (OA), but little is known about patients' attitudes towards these therapies. We aimed to better understand patients' perceptions of the facilitators of and barriers to IA injections for knee OA. Methods We conducted a qualitative, descriptive/exploratory study and held focus groups and individual interviews with participants with knee OA, including some who had received IA injections and others who had not received IA injections. We conducted a thematic analysis to identify themes describing the factors participants found influential when deciding whether to try an IA injection. Results We held three focus groups with 12 participants and conducted three individual interviews (15 participants total). We identified four themes that shaped participants' decisions to receive a specific injection: 1) the impact of OA on participants' lives; 2) participants' attitudes and concerns, including desire to avoid surgery, willingness to accept uncertain outcomes, and concerns about side effects and dependence; 3) the way participants gathered and processed information from physicians, peers, and the internet; and 4) availability of injectable products. Participants weighed the desire to regain function and delay surgery with concerns about side effects, uncertain efficacy, and costs. Conclusion Participants were concerned about the effectiveness, toxicity, availability, and cost of injectable products. They balanced disparate sources of information, uncertain outcomes, limited product availability, and other injection-related concerns with a desire to decrease pain. These findings can provide clinicians, investigators, and public health professionals with insights into challenges patients face when making injection decisions.

Objectives Over the last decade, there has been increased use of end-tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) monitoring during resuscitation of prematurely born infants in the delivery suite. Our objectives were to test the hypotheses that low end-tidal carbon dioxide (ETCO2) levels, low oxygen saturations (SpO2) and high expiratory tidal volumes (VTE) during the early stages of resuscitation would be associated with adverse outcomes in preterm infants. Methods Respiratory recordings made in the first 10 min of resuscitation in the delivery suite of 60 infants, median GA 27 (interquartile range 25–29) weeks were analysed. The results were compared of infants who did or did not die or did or did not develop intracerebral haemorrhage (ICH) or bronchopulmonary dysplasia (BPD). Results Twenty-five infants (42%) developed an ICH and 23 (47%) BPD; 11 (18%) died. ETCO2 at approximately 5 min after birth was lower in infants who developed an ICH, this remained significant after adjusting for gestational age, coagulopathy and chorioamnionitis (p=0.03). ETCO2 levels were lower in infants who developed ICH or died compared to those that survived without ICH, which remained significant after adjustment for gestational age, Apgar score at 10 min, chorioamnionitis and coagulopathy (p=0.004). SpO2 at approximately 5 min was lower in the infants who died compared to those who survived which remained significant after adjusting for the 5-min Apgar score and chorioamnionitis (p=0.021). Conclusions ETCO2 and SpO2 levels during early resuscitation in the delivery suite were associated with adverse outcomes.

Objectives Corticosteroids are administered to ventilator dependent infants with bronchopulmonary dysplasia (BPD) to improve respiratory function and facilitating extubation. Acutely, however, growth impairment can occur as a side effect of such therapy. We aimed to determine the effect of corticosteroids on postnatal growth during the entire neonatal intensive care unit (NICU) admission. Methods A whole population study of extremely preterm infants with BPD was undertaken. Corticosteroid therapy was classified as treatment with dexamethasone or hydrocortisone for a least five consecutive days. Growth was calculated as the difference in weight and head circumference z-score from birth to discharge. Results Six thousand, one hundred and four infants with BPD were included of whom 28.3% received postnatal corticosteroids. Infants receiving corticosteroids were less mature (GA 25.0 vs. 26.3 weeks) and of lower birthweight (0.70 vs. 0.84 kg) than those not receiving treatment. There were no significant differences between those who did and did not receive corticosteroids in weight gain (p=0.61) or head circumference growth (p=0.33) from birth to discharge. Single vs. multiple courses of postnatal corticosteroids did not result in significant differences in weight (p=0.62) or head circumference (p=0.13) growth. Conclusions Postnatal corticosteroid treatment did not affect the longer term growth of preterm infants with BPD.

Background Volumetric capnography allows for continuous monitoring of expired tidal volume and carbon dioxide. The slope of the alveolar plateau of the capnogram (SIII) could provide information regarding ventilation homogeneity. We aimed to assess the feasibility of measuring SIII during newborn resuscitation and determine if SIII decreased after surfactant indicating ventilation inhomogeneity improvement. Methods Respiratory function traces of preterm infants resuscitated at birth were analysed. Ten capnograms were constructed for each infant: five pre- and post-surfactant. If a plateau was present SIII was calculated by regression analysis. Results Thirty-six infants were included, median gestational age of 28.7 weeks and birth weight of 1055 g. Average time between pre- and post-surfactant was 3.2 min. Three hundred and sixty capnograms (180 pre and post) were evaluated. There was adequate slope in 134 (74.4%) capnograms pre and in 100 (55.6%) capnograms post-surfactant (p = 0.004). Normalised for tidal volume SIII pre-surfactant was 18.89 mmHg and post-surfactant was 24.86 mmHg (p = 0.006). An increase in SIII produced an up-slanting appearance to the plateau indicating regional obstruction. Conclusion It was feasible to evaluate the alveolar plateau pre-surfactant in preterm infants. Ventilation inhomogeneity increased post-surfactant likely due to airway obstruction caused by liquid surfactant present in the airways. Impact Volumetric capnography can be used to assess homogeneity of ventilation by SIII analysis. Ventilation inhomogeneity increased immediately post-surfactant administration during the resuscitation of preterm infants, producing a characteristic up-slanting appearance to the alveolar plateau. The best determinant of alveolar plateau presence in preterm infants was the expired tidal volume.

ObjectiveTo use cluster analysis to identify discrete phenotypic groups of extremely preterm infants.DesignSecondary analysis of a retrospective whole population study.SettingAll neonatal units in England between 2014 and 2019.ParticipantsInfants live-born at less than 28 weeks of gestation and admitted to a neonatal unit.InterventionsK-means cluster analysis was performed with the gestational age, Apgar score at 5 min and duration of mechanical ventilation as input variables.Primary and secondary outcome measuresBronchopulmonary dysplasia, discharge on home oxygen, intraventricular haemorrhage, death before discharge from neonatal care.ResultsTen thousand one hundred and ninety-seven infants (53% male) were classified into four clusters: Cluster 1 contained infants with intermediate gestation and duration of ventilation and had an intermediate mortality and incidence of bronchopulmonary dysplasia. Cluster 2 contained infants with the highest gestation, a shorter duration of ventilation and the lowest mortality. Cluster 3 contained infants with the lowest Apgar score and highest mortality and incidence of intraventricular haemorrhage. Cluster 4 contained infants with the lowest gestation, longest duration of ventilation and highest incidence of bronchopulmonary dysplasia.ConclusionClinical parameters can classify extremely preterm infants into discrete phenotypic groups with differing subsequent neonatal outcomes.

Abnormal levels of end-tidal carbon dioxide (EtCO2) during resuscitation in the delivery suite are associated with intraventricular haemorrhage (IVH) development. Our aim was to determine whether carbon dioxide (CO2) levels in the first 3 days after birth reflected abnormal EtCO2 levels in the delivery suite, and hence, a prolonged rather than an early insult resulted in IVH. In addition, we determined if greater EtCO2level fluctuations during resuscitation occurred in infants who developed IVH. EtCO2 levels during delivery suite resuscitation and CO2 levels on the neonatal unit were evaluated in 58 infants (median gestational age 27.3 weeks). Delta EtCO2 was the difference between the highest and lowest level of EtCO2. Thirteen infants developed a grade 3–4 IVH (severe group). There were no significant differences in CO2 levels between those who did and did not develop an IVH (or severe IVH) on the NICU. The delta EtCO2 during resuscitation differed between infants with any IVH (6.2 (5.4–7.5) kPa) or no IVH (3.8 (2.7–4.3) kPA) (p < 0.001) after adjusting for differences in gestational age. Delta EtCO2 levels gave an area under the ROC curve of 0.940 for prediction of IVH.Conclusion: The results emphasize the importance of monitoring EtCO2 levels in the delivery suite. What is Known:• Abnormal levels of carbon dioxide (CO2) in the first few days after birth and abnormal end-tidal CO2levels (EtCO2) levels during resuscitation are associated in preterm infants with the risk of developing intraventricular haemorrhage (IVH). What is New:• There were no significant differences in NICU CO2levels between those who developed an IVH or no IVH.• There was a poor correlation between delivery suite ETCO2levels and NICU CO2levels.• Large fluctuations in EtCO2during resuscitation in the delivery suite were highly predictive of IVH development in preterm infants.

Mechanical ventilation can be life-saving for the premature infant, but is often injurious to immature and underdeveloped lungs. Lung injury is caused by atelectrauma, oxygen toxicity, and volutrauma. Lung protection must include appropriate lung recruitment starting in the delivery suite and throughout mechanical ventilation. Strategies include open lung ventilation, positive end-expiratory pressure, and volume-targeted ventilation. Respiratory function monitoring, such as capnography and ventilator graphics, provides clinicians with continuous real-time information and an adjunct to optimize lung-protective ventilatory strategies. Further research is needed to assess which lung-protective strategies result in a decrease in long-term respiratory morbidity.

BackgroundNeonatal units across the world have altered their policies to prevent the spread of infection during the COVID-19 pandemic. Our aim was to report parental experience in two European neonatal units during the pandemic.MethodsParents of infants admitted to each neonatal unit were asked to complete a questionnaire regarding their experience during the COVID-19 pandemic. At King’s College Hospital, UK (KCH), data were collected prospectively between June 2020 and August 2020 (first wave). At the Hospital Clínic Barcelona (HCM), data were collected retrospectively from parents whose infants were admitted between September 2020 and February 2021 (second and third wave).ResultsA total of 74 questionnaires were completed (38 from KCH and 36 from HCM). The parents reported that they were fully involved or involved in the care of their infants in 34 (89.4%) responses in KCH and 33 (91.6%) responses in HCM. Quality time spent with infants during the pandemic was more negatively affected at KCH compared with HCM (n=24 (63.2%) vs n=12 (33.3%)). Parents felt either satisfied or very satisfied with the updates from the clinical care team in 30 (79.0%) responses at KCH and 30 (83.4%) responses in HCM. The parents felt that the restrictions negatively affected breast feeding in six (15.8%) responses at KCH and two (5.6%) responses in HCM. Travelling to the hospital was reported overall to be sometimes difficult (39.2%); this did not differ between the two units (14 (36.8%) respondents at KCH and 15 (41.6%) from HCM). Furthermore, the self-reported amount of time spent giving kangaroo care also did not differ between the two countries.ConclusionRestrictive policies implemented due to the COVID-19 pandemic had a negative impact on the perception of quality of time spent by parents with their newborns admitted to neonatal units.

To report the effect of antenatal corticosteroids (ANS) on mortality, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD) and the duration of ventilation according to sex in extremely preterm infants.All extremely preterm infants admitted to any neonatal unit in England between 2014 and 2019.Eleven thousand seven hundred and fourteen infants (54% male) were included with a median (IQR) gestational age of 26 + 1 (24 + 6 - 27 + 1) weeks, birth weight of 809 (670 - 960) grams and birth weight z-score of -0.38 (-0.88 to 0.07). ANS were administered in 10,449 infants (89%); equally in males and females. Infants who received ANS compared to those who did not, had a lower mortality before discharge (18.7 versus 32.3%,Antenatal corticosteroids had a greater beneficial effect in female compared to male extremely prematurely born infants in reducing death before discharge.

Background Nicotine replacement therapy (NRT) and e-cigarettes are recommended to pregnant women who wish to stop smoking. Albeit eliminating other harmful components of cigarettes, those alternatives still expose the developing fetus to nicotine. The lungs may be particularly vulnerable to damage by nicotine as there is widespread nicotinic-acetylcholine receptor expression in the lungs. There is, however, a paucity of information about the effect of NRT and e-cigarette use in pregnancy on infant respiratory outcomes. Aims To explore the effect of NRT and e-cigarettes on the developing lung. Study design A literature search was undertaken to examine the use and safety of nicotine-replacement strategies in pregnancy, with a focus on infant respiratory outcomes. This included experimental studies investigating the effect of isolated “gestational” nicotine on the developing lung. Outcome measures Respiratory outcomes in animal studies and infants. Results Animal studies investigating the effect of gestational nicotine exposure on fetal lung development demonstrated abnormal lung growth; including abnormal airway branching and alveolar development. Consequently, offspring display altered pulmonary mechanics, including both increased respiratory rate and airway resistance. These findings mirror respiratory pathology observed in infants born to smoking mothers. Human trials of NRT and e-cigarette use in pregnancy have not identified adverse perinatal outcomes regarding reduced birthweight or prematurity, but have not considered infant and childhood respiratory outcomes. Conclusions Nicotine can impair fetal lung development, leading to concerns regarding the safety of NRT and e-cigarettes in pregnancy. Studies have yet to explore the impact of these nicotine-containing products on infant respiratory outcomes.

To determine whether the duration of invasive ventilation predicted the development of bronchopulmonary dysplasia (BPD) and need for discharge home on supplementary oxygen in extremely preterm infants.Retrospective whole-population study of all infants28 weeks of gestation admitted to a neonatal unit in England between 2014 and 2018. BPD development was defined as any respiratory support at 36 weeks postmenstrual age. The performance of the duration of mechanical ventilation to predict BPD or discharge home on oxygen was assessed by receiver operator characteristic curve analysis.The 11,806 infants had a median (IQR) gestational age of 26.0(24.9-27.1) weeks and birthweight of 0.81(0.67-0.96) kg. At discharge from neonatal care, 9,415 infants (79.7%) were alive. The incidence of BPD was 57.5% and of home oxygen 29.4%. Mechanical ventilation duration had areas under the curve of 0.793 and 0.703 in predicting BPD and home oxygen, respectively. Mechanical ventilation for8 days predicted BPD development with 71% sensitivity and 71% specificity and mechanical ventilation for10 days predicted discharge on home oxygen with 66% sensitivity and 65% specificity.In extremely preterm infants, the duration of invasive support predicted BPD and need for home oxygen with moderate sensitivity and specificity.

Non-invasive ventilation (NIV) is being utilised more frequently to reduce the need for invasive ventilation within the neonatal population. An example of one mode of NIV is bi-level continuous positive airway pressure (BiPAP). BiPAP delivers a lower pressure (usually 4-6 cm H2 O) interchanging with a higher-level pressure, which is conventionally set 3-5 cm H2 O above the basal pressure 1,2 . The provision of two alternating pressures may offer benefits beyond the sole provision of a basal pressure, as in continuous positive airway pressure (CPAP) ventilation.

AIM To determine whether closed loop automated oxygen control resulted in a reduction in the duration and severity of desaturation episodes and the number of blood gases and chest radiographs in preterm, ventilated infants. METHODS Infants were studied on two consecutive days for 12 hours on each day. They were randomised to receive standard care (standard period) or standard care with a closed loop automated oxygen control system (automated oxygen control period) first. RESULTS Twenty-four infants with a median gestational age of 25.7 (range 23.1-32.6) weeks were studied at a median postconceptional age of 27.4 (range 24.3-34.9) weeks. During the automated oxygen control period, there were fewer desaturations that lasted >30 seconds (P = .032) or >60 seconds (P = .002), infants spent a higher proportion of the time within their target SpO2 range during the automated oxygen control period (P

Parasites are commonly cited as one of the causes of population declines for both managed and wild bees. Epidemiological models sometimes assume that increasing the proportion of infected individuals in a group should increase transmission. However, social insects exhibit behaviors and traits which can dampen the link between parasite pressure and disease spread. Understanding patterns of parasite transmission within colonies of social bees has important implications for how to control diseases within those colonies, and potentially the broader pollinator community. We used bumble bees (Bombus impatiens Cresson) (Hymenoptera: Apidae) and western honey bees (Apis mellifera L.) (Hymenoptera: Apidae) infected with the gut parasites Crithidia bombi (Lipa & Triggiani) (Trypanosomatida: Trypanosomatidae) and Nosema ceranae (Fries et al.) (Dissociodihaplophasida: Nosematidae), respectively, to understand how the initial proportion of infected individuals impacts within-colony spread and intensity of infection of the parasites. In bumble bees, we found that higher initial parasite prevalence increased both the final prevalence and intensity of infection of C. bombi. In honey bees, higher initial prevalence increased the intensity of infection in individual bees, but not the final prevalence of N. ceranae. Measures that reduce the probability of workers bringing parasites back to the nest may have implications for how to control transmission and/or severity of infection and disease outbreaks, which could also have important consequences for controlling disease spread back into the broader bee community.

Purpose We performed a qualitative study to understand the psychosocial factors associated with success in upper-extremity vascularized composite allotransplantation from the perspective of transplant providers. Methods We recruited 13 providers actively involved in upper-extremity vascularized composite allotransplantation. Participants included physicians, nurses, social workers, occupational therapists, and research administrators. We conducted semistructured face-to-face focus group interviews using a guide that explored providers’ perceptions of qualities contributing to transplant outcome. Topics included social support networks and their influence on recovery, barriers to treatment compliance and successful posttransplant rehabilitation, and the process of setting patients’ expectations. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study’s guiding questions. Results The analysis identified numerous factors that contribute to transplant success: (1) recipients’ prior experiences modify their ability to cope and adapt after transplantation, (2) behaviors and characteristics such as positivity influence candidacy and may be predictive of successful outcomes, and (3) social support is essential for improved function and compliance. The provider care team cited difficulty in predicting recipient compliance and in setting realistic expectations. Conclusions Motivated recipients with developed coping and resiliency, a positive attitude, and stable, physically-able caregivers are perceived by providers to have greater success after transplantation. Clinical Relevance Findings from this work may help providers determine optimal candidates for upper-extremity vascularized composite allotransplantation.

Carboxyhaemoglobin (COHb) levels may reflect the level of early oxidative stress which plays a role in mediating free-radical-related diseases in prematurely born infants.To assess the relationship of COHb levels in the first seven days of after birth to the development of bronchopulmonary dysplasia (BPD) and other free-radical-related diseases.Retrospective analysis of routinely performed COHb via blood gas samples of infants born at less than 30 weeks of gestation admitted to a tertiary neonatal intensive care unit was undertaken.One hundred and four infants were included with a median (range) gestational age of 27.4 (22.4-29.9) weeks and a birthweight of 865 (395-1710) grams.The maximum COHb per infant per day was recorded for the first 28 days and BPD and other free-radical-related diseases including intraventricular haemorrhage (IVH) were noted. The severity of BPD, requirement for home oxygen on discharge and survival to discharge were also recorded.Infants who developed BPD (n = 76) had significantly higher COHb levels in the first seven days [1.7% (0.3-6.8)] compared to those that did not develop BPD [1.6% (0.9-3.8); p = 0.001]. Higher COHb levels in the first seven days after birth were also observed in infants with grade three/four IVH [n = 20; 1.9% (1.0-6.8)] compared to those without [1.6% (0.3-5.6); p 0.001]. COHb levels, however, were not associated with the duration of ventilation, BPD severity or survival to discharge.Higher COHb levels in prematurely born infants were associated with the development of BPD and IVH.

Invasive mechanical ventilation in the neonatal setting can be life-saving, but may lead to chronic respiratory morbidity. As a consequence, there has been a focus on using non-invasive ventilation techniques (NIV). One NIV mode is bilevel continuous positive airway pressure (BiPAP), during which two alternating levels of pressure are delivered: a lower/baseline pressure (usually 4-6 cm H2 O) and an upper pressure (usually 3-5 cm H2 O above the lower continuous positive airway pressure (CPAP) level) which is delivered at a set rate with a specified inspiratory time (usually 0.5-1 seconds) (1).

Objectives Infants receiving care from neonatal intensive care unit (NICU) can develop chronic problems and be transferred to a paediatric intensive care unit (PICU) for on-going care. There is concern that such infants may take up a large amount of PICU resource, but this is not evidence based. We determined the impact of such transfers. Methods We reviewed 10 years of NICU admissions to two tertiary PICUs, which had approximately 12,000 admissions during that period. Results Sixty-seven infants, gestational age at birth 34.7 (IQR 27.1–38.8) weeks and postnatal age on transfer 81 (IQR 9–144) days were admitted from NICUs. The median (IQR) length of stay was 12 (4–41) days. The 19 infants born Conclusions Infants transferred from NICUs were a small proportion of PICU admissions but, particularly those born

Administration of caffeine citrate can facilitate extubation. Our aim was to determine whether a loading dose of caffeine citrate given to ventilated, preterm infants affected the diaphragm electrical activity.Infants34 weeks of gestational age were recruited if requiring mechanical ventilation and prescribed a loading dose of caffeine citrate. Surface electrodes recorded the electrical activity of the diaphragm (dEMG) before and after administration of intravenous caffeine citrate. The mean amplitude of the EMG (dEMG) trace and the mean area under the EMG curve (aEMGc) were calculated.Thirty-two infants were assessed with a median gestational age of 29 (27-31) weeks. The dEMG amplitude increased, peaking at 25 min post administration (p = 0.006), and the increase in aEMGc (p = 0.004) peaked at 30 min; the differences were not significant after 60 min. At 20 min, there was an increase in minute volume (p = 0.034) and a reduction in the peak inspiratory pressure (p = 0.049).We have demonstrated a transient increase in both electrical activity of the diaphragm and respiratory function following an intravenous loading dose of caffeine citrate.

To compare the outcomes of infants with a right (RCDH) versus a left-sided (LCDH) congenital diaphragmatic hernia (CDH) and whether these differed according to whether the infants had undergone fetoscopic tracheal occlusion (FETO). Demographics, the type of surgical repair, preoperative and postoperative courses and respiratory, gastrointestinal, surgical and skeletal morbidities at follow-up were compared between infants with a RCDH or LCDH. A sub-analysis was undertaken in those who had undergone FETO. During the study period, there were 167 infants with a LCDH and 24 with a RCDH; 106 underwent FETO (15 RCDH). Overall, the need for inhaled nitric oxide (p = 0.036) was higher in the RCDH group and, at follow-up, infants with RCDH were more likely to have a hernia recurrence (p = 0.043), pectus deformity (p = 0.019), scoliosis (p = 0.029) and suffer chronic respiratory morbidity (p = 0.001). There were, however, no significant differences in short term or long term outcomes (hernia recurrence (p = 0.237), pectus deformity (p = 0.322), scoliosis (p = 0.0174) or chronic respiratory morbidity (p = 0.326)) between infants with a right or left sided CDH who had undergone FETO. Overall, infants with a RCDH compared to those with a LCDH had greater long-term morbidity, but not if they had undergone FETO.

Background: Administration of caffeine citrate can facilitate extubation. Our aim was to determine whether a loading dose of caffeine citrate given to ventilated, preterm infants affected the diaphragm electrical activity. Methods: Infants

A female infant with antenatally diagnosed trisomy 21 was delivered at 27 weeks. She was intubated at birth and given surfactant. A day 3 echocardiogram three showed a structurally normal heart, but severe pulmonary hypertension (PH). She required oscillation, nitric oxide and inotropes. At 1 week, she developed necrotising enterocolitis (NEC) and a perforation requiring resection and ileostomy formation. A subsequent echocardiogram showed resolved PH. She was …

Background On the neonatal unit less invasive surfactant administration (LISA) reduces BPD and the need for mechanical ventilation. Aims To evaluate the feasibility of LISA in the delivery suite and to undertake respiratory function physiological monitoring before and after LISA. Study design A prospective, observational cohort study was undertaken. A LISA simulation training programme was delivered. Then, LISA was undertaken in infants with respiratory distress maintained on continuous positive airway pressure (CPAP) in the delivery suite using videolaryngoscopic guidance without sedation. Subjects Thirty-eight infants with a median (IQR) gestational age of 31 + 5 weeks (30+3–33+4) and birth weight of 1.61 (1.42–1.90) kg had LISA in the delivery suite. Outcome measures Adverse effects of LISA and whether LISA resulted in changes in tidal and minute volumes, end tidal carbon dioxide (EtCO2) levels and the inspired oxygen concentration (FiO2). Results Respiratory function monitoring was available for 34 of the infants. LISA occurred at a median (IQR) interval of 18 (15–29) minutes after birth. The most common adverse events were desaturation (44.7%) and surfactant reflux (39.5%), both responded to either temporary suspension of LISA or slowing the speed of surfactant administration. Following LISA, there was a significant reduction in respiratory rate 2 min later (p Conclusions LISA is feasible in the delivery suite after appropriate training of staff. It can be undertaken without serious adverse effects and results in a reduction in respiratory distress and improvement in oxygenation.

We read with interest the study by Scrivens et al ,1 which evaluated the evidence on the applicability of waveform capnography in neonatal intensive care. While in principle we agree that currently there is insufficient evidence to support the routine application of tidal capnography in clinical practice, we would like to describe some more recent developments that could inform future clinical practice and research. The authors highlight that end-tidal carbon dioxide (ET-CO2) values under-read the true arterial CO2 and that agreement between arterial and ET-CO2 decreases with increasing severity of lung disease, suggesting a decreased reliability of the method in those babies who require the closest monitoring. The ET-CO2 value, …