Maternal age at pregnancy is increasing worldwide as well as preterm birth. However, the association between prematurity and advanced maternal age remains controversial.
To evaluate the impact of ...maternal age on the occurrence of preterm birth after controlling for multiple known confounders in a large birth cohort.
Retrospective cohort study using data from the QUARISMA study, a large Canadian randomized controlled trial, which collected data from 184,000 births in 32 hospitals. Inclusion criteria were maternal age over 20 years. Exclusion criteria were multiple pregnancy, fetal malformation and intra-uterine fetal death. Five maternal age categories were defined and compared for maternal characteristics, gestational and obstetric complications, and risk factors for prematurity. Risk factors for preterm birth <37 weeks, either spontaneous or iatrogenic, were evaluated for different age groups using multivariate logistic regression.
165,282 births were included in the study. Chronic hypertension, assisted reproduction techniques, pre-gestational diabetes, invasive procedure in pregnancy, gestational diabetes and placenta praevia were linearly associated with increasing maternal age whereas hypertensive disorders of pregnancy followed a "U" shaped distribution according to maternal age. Crude rates of preterm birth before 37 weeks followed a "U" shaped curve with a nadir at 5.7% for the group of 30-34 years. In multivariate analysis, the adjusted odds ratio (aOR) of prematurity stratified by age group followed a "U" shaped distribution with an aOR of 1.08 (95%CI; 1.01-1.15) for 20-24 years, and 1.20 (95% CI; 1.06-1.36) for 40 years and older. Confounders found to have the greatest impact were placenta praevia, hypertensive complications, and maternal medical history.
Even after adjustment for confounders, advanced maternal age (40 years and over) was associated with preterm birth. A maternal age of 30-34 years was associated with the lowest risk of prematurity.
Summary Background Post-thrombotic syndrome (PTS) is a common and burdensome complication of deep venous thrombosis (DVT). Previous trials suggesting benefit of elastic compression stockings (ECS) to ...prevent PTS were small, single-centre studies without placebo control. We aimed to assess the efficacy of ECS, compared with placebo stockings, for the prevention of PTS. Methods We did a multicentre randomised placebo-controlled trial of active versus placebo ECS used for 2 years to prevent PTS after a first proximal DVT in centres in Canada and the USA. Patients were randomly assigned to study groups with a web-based randomisation system. Patients presenting with a first symptomatic, proximal DVT were potentially eligible to participate. They were excluded if the use of compression stockings was contraindicated, they had an expected lifespan of less than 6 months, geographical inaccessibility precluded return for follow-up visits, they were unable to apply stockings, or they received thrombolytic therapy for the initial treatment of acute DVT. The primary outcome was PTS diagnosed at 6 months or later using Ginsberg's criteria (leg pain and swelling of ≥1 month duration). We used a modified intention to treat Cox regression analysis, supplemented by a prespecified per-protocol analysis of patients who reported frequent use of their allocated treatment. This study is registered with ClinicalTrials.gov , number NCT00143598 , and Current Controlled Trials, number ISRCTN71334751. Findings From 2004 to 2010, 410 patients were randomly assigned to receive active ECS and 396 placebo ECS. The cumulative incidence of PTS was 14·2% in active ECS versus 12·7% in placebo ECS (hazard ratio adjusted for centre 1·13, 95% CI 0·73–1·76; p=0·58). Results were similar in a prespecified per-protocol analysis of patients who reported frequent use of stockings. Interpretation ECS did not prevent PTS after a first proximal DVT, hence our findings do not support routine wearing of ECS after DVT. Funding Canadian Institutes of Health Research.
Background Red blood cell transfusion is an important supportive measure after pediatric cardiac operations. However, no clear hemoglobin threshold has been established. This study characterized ...anemia development and red blood cell transfusions in the pediatric intensive care unit (PICU) after cardiac operations. Methods A prospective, multicenter, 6-month cohort study on the management of anemia in critically ill pediatric patients was conducted in 30 North American PICUs. This observational study enrolled 977 consecutive children (aged <18 years) who stayed in the PICU for 48 hours or more. We analyzed a subgroup of postcardiac surgical patients from this study. Results Included were 175 cardiac patients, 56% of whom had cyanotic heart disease. The mean Pediatric Risk of Mortality (PRISM III) score was 6.4 ± 5.4. Fifty-four percent of children were anemic in the PICU (20% on admission, 34% during PICU stay). Most patients (79%) received at least one red blood cell transfusion in the PICU. Patients who received a transfusion had a significantly longer PICU stay (9.3 ± 6.3 vs 6.1 ± 5.4 days, p = 0.01). Pretransfusion hemoglobin was different in acyanotic and cyanotic patients (mean ± standard deviation: 11.1 ± 2.2 g/dL and 11.8 ± 2.1 g/dL, respectively). According to the attending physician, a low hemoglobin level was the primary indication for transfusion in only 17% of cases. Conclusions Pediatric cardiac surgical patients are at high risk of receiving red blood cell transfusions. This study, which showed great variability in transfusion practices across North American PICUs, highlights the need for clearer transfusion guidelines in this specific population.
Background
Bronchiolitis is the leading cause of hospitalisation among infants in high‐income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. ...Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high‐resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis.
Objectives
To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores).
Search methods
We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009).
Selection criteria
Randomised controlled trials (RCTs) and quasi‐RCTs of heliox in infants with acute bronchiolitis.
Data collection and analysis
Two review authors independently extracted data and assessed trial quality.
Main results
We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.
When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).
There was no decrease in the length of treatment for respiratory distress: mean difference (MD) ‐0.19 days (95% CI ‐0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD ‐0.76 days (95% CI ‐1.45 to ‐0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.
We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD ‐1.04 (95% CI ‐1.60 to ‐0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high‐concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m‐WCAS) in infants treated with heliox ranging from less than two to more than seven.
Authors' conclusions
Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.
Questions remain regarding the timing and quantity of red-cell transfusions in pediatric intensive care units. This study involving stable, critically ill children showed that a restricted strategy ...(transfusion threshold, 7 g of hemoglobin per deciliter) was as safe as a liberal strategy (transfusion threshold, 9.5 g per deciliter). Rates of multiple-organ dysfunction were similar in the two study groups.
This study involving stable, critically ill children showed that a restricted strategy (transfusion threshold, 7 g of hemoglobin per deciliter) was as safe as a liberal strategy (transfusion threshold, 9.5 g per deciliter).
Up to 50% of children who are hospitalized in an intensive care unit (ICU) receive red-cell transfusions,
1
,
2
yet children whose condition is stable may tolerate the decreased oxygen delivery associated with a moderate degree of anemia. On the one hand, transfusions containing leukocytes could have limited benefit in such children and might result in organ dysfunction through stimulation of the inflammatory cascade by the transfused leukocytes.
3
On the other hand, children in the ICU could benefit from transfusions because of enhanced oxygen delivery, just as adults with early septic shock benefit from transfusions.
4
A randomized trial involving 838 critically . . .
Background
IgA nephropathy (IgAN) and Henoch-Schönlein purpura are common glomerular disorders in children sharing the same histopathologic pattern of IgA deposits within the mesangium, even if their ...physiopathology may be different. Repeated exposure to pathogens induces the production of abnormal IgA1. The immune complex deposition in the renal mesangium in IgAN or potentially in small vessels in Henoch-Schönlein purpura induces complement activation via the alternative and lectin pathways. Recent studies suggest that levels of membrane attack complex (MAC) in the urine might be a useful indicator of renal injury. Because of the emerging availability of therapies that selectively block complement activation, the aim of the present study is to investigate whether MAC immunostaining might be a useful marker of IgA-mediated renal injury.
Methods
We conducted immunohistochemistry analysis of the MAC on renal biopsies from 67 pediatric patients with IgAN and Henoch-Schönlein purpura. We classified their renal biopsies according to the Oxford classification, retrieved symptoms, biological parameters, treatment, and follow-up.
Results
We found MAC expression was significantly related to impaired renal function and patients whose clinical course required therapy. MAC deposits tend to be more abundant in patients with decreased glomerular filtration rate (
p
= 0.02), patients with proteinuria > 0.750 g/day/1.73 m
2
, and with nephrotic syndrome. No correlation with histological alterations was observed.
Conclusions
We conclude that MAC deposition could be a useful additional indicator of renal injury in patients with IgAN and Henoch-Schönlein purpura, independent of other indicators.
A universal newborn screening program for sickle cell disease (uNS‐SCD) was implemented in the province of Québec (Qc) in November 2013, close in time to the recommendation of early initiation of ...hydroxyurea (HU) therapy for children. This retrospective cohort study evaluated the impact of such a program on children first seen between January 2000 and December 2019. Cohorts pre‐SCD‐uNS in Qc (pre‐QcNS) (n = 253) and post‐QcNS (n = 157) for patients seen prior to or after Nov 2013 were compared. Kaplan‐Meier curves, Poisson regression, and logistic regressions were used for statistical analysis, using Software R version 4.2.1. Median age at first visit decreased significantly from 14.4 interquartile range: 2.4–72.0 to 1.2 months 1.2–57.6 (p < 0.001). The percentage of children born in Qc undiagnosed at birth and referred after a first SCD‐related complication dropped from 42.6% to 0.0% (p < 0.0001). The median age of HU introduction for patients with SS/Sβ°‐thalassemia decreased from 56.4 31.2–96.0 to 9.0 months post‐QcNS 8.0–12.1 (p < 0.001). Event‐free survival improved significantly for any type of hospitalization as well as for vaso‐occlusive crisis (VOC) (140–257 days (p < 0.001) and 1320 vs. 573 days (p < 0.002), respectively), resulting in a reduction from 2 interquartile range: 1.0–3.0 to 1.0 hospitalizations/patient‐year 0.6–1.4 (p < 0.001). Children with SS/Sβ°‐thalassemia referred post‐QcNS also had fewer emergency department visits for VOC (RR: 0.69, 95% confidence interval: 0.54–0.88). The Universal NS program allows early detection and referral of children with SCD to comprehensive care centers. Earlier access ensures that children benefit from essential preventive interventions, reducing disease burden. This cohort study highlights that uNS‐SCD is an essential public health measure.
OBJECTIVE:To determine the impact of a restrictive vs. a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome in children post cardiac surgery. The optimal ...transfusion threshold after cardiac surgery in children is unknown.
DESIGN:Randomized, controlled trial.
SETTING:Tertiary pediatric intensive care units.
PATIENTS:Participants are a subgroup of pediatric patients post cardiac surgery from the TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units) study. Exclusion criteria specific to the cardiac surgery subgroup includedage <28 days and patients remaining cyanotic.
INTERVENTION:Critically ill children with a hemoglobin ≤95 g/L within 7 days of pediatric intensive care unit admission were randomized to receive prestorage leukocyte-reduced red-cell transfusion if their hemoglobin dropped either <70 g/L (restrictive) or 95 g/L (liberal).
MEASUREMENTS AND MAIN RESULTS:Postoperative cardiac patients (n = 125) from seven centers were enrolled. The restrictive (n = 63) and liberal (n = 62) groups were similar at baseline in age (mean ± standard deviation = 31.4 ± 38.1 mos vs. 26.4 ± 39.1 mos), surgical procedure, severity of illness (Pediatric Risk of Mortality score = 3.4 ± 3.2 vs. 3.2 ± 3.2), multiple organ dysfunction syndrome (46% vs. 44%), mechanical ventilation (62% vs. 60%), and hemoglobin (83 vs. 80 g/L). Mean hemoglobin remained 21 g/L lower in the restrictive group after randomization. No significant difference was found in new or progressive multiple organ dysfunction syndrome (primary outcome) in the restrictive group vs. liberal group (12.7% vs. 6.5%; p = .36), pediatric intensive care unit length of stay (7.0 ± 5.0 days vs. 7.4 ± 6.4 days) or 28-day mortality (3.2% vs. 3.2%).
CONCLUSION:In this subgroup analysis of cardiac surgery patients, a restrictive red-cell transfusion strategy, as compared with a liberal one, was not associated with any significant difference in new or progressive multiple organ dysfunction syndrome, but this evidence is not definitive.
MF59®-adjuvanted trivalent inactivated influenza vaccine (aIIV3) and high-dose trivalent inactivated influenza vaccine (HD-IIV3) elicit an enhanced immune response in older adults compared to ...standard, quadrivalent inactivated influenza vaccines (IIV4). We sought to determine the relative vaccine effectiveness (rVE) of aIIV3 versus IIV4 and HD-IIV3 in preventing influenza-related medical encounters in this retrospective cohort study involving adults ≥65 years with ≥1 health condition during the 2017–2018 and 2018–2019 influenza seasons. Data were obtained from primary and specialty care electronic medical records linked with pharmacy and medical claims. Adjusted odds ratios (OR) were derived from an inverse probability of treatment-weighted sample adjusted for age, sex, race, ethnicity, geographic region, vaccination week, and health status. rVE was determined using the formula (% rVE = 1 − ORadjusted) × 100. Analysis sets included 1,755,420 individuals for the 2017–2018 season and 2,055,012 for the 2018–2019 season. Compared to IIV4, aIIV3 was 7.1% (95% confidence interval 3.3–10.8) and 20.4% (16.2–24.4) more effective at preventing influenza-related medical encounters in the 2017–2018 and 2018–2019 seasons, respectively. Comparable effectiveness was observed with HD-IIV3 across both seasons. Our results support improved effectiveness of aIIV3 vs IIV4 in a vulnerable population of older adults at high risk of influenza and its complications.
Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and ...decrease the work of breathing.
To assess heliox in addition to standard medical care for acute bronchiolitis in infants.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2), which includes the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1966 to June 2009), EMBASE (June 2009), LILACS (May 2009) and the NIH web site (May 2009).
Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis.
Two review authors independently extracted data and assessed trial quality. We pooled data from individual trials.
We included four trials involving 84 infants under two years of age with respiratory distress secondary to bronchiolitis caused by respiratory syncytial virus (RSV) and requiring paediatric intensive care unit (PICU) hospitalisation. We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation (mean difference (MD) -1.15, 95% confidence interval (CI) -1.98 to -0.33, P = 0.006, n = 69). There was no clinically significant reduction in the rate of intubation (risk ratio (RR) 1.38, 95% CI 0.41 to 4.56, P = 0.60, n = 58), in the need for mechanical ventilation (RR 1.11, 95% CI 0.36 to 3.38, P = 0.86, n = 58), or in the length of stay in a PICU (MD = -0.15 days, 95% CI -0.92 to 0.61, P = 0.69, n = 58). No adverse events related to heliox inhalation were reported.
Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. Nevertheless, there was no reduction in the rate of intubation, in the need for mechanical ventilation, or in the length of PICU stay. Further studies with homogeneous logistics in their heliox application are needed. Such studies would provide necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.
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