O desenvolvimento da alergia pode ter início precoce, durante os primeiros meses de vida ou ainda durante a gestação. Em camundongos, é descrita uma predisposição ao desenvolvimento de resposta Th2 no período neonatal, contribuindo para o desenvolvimento da resposta alérgica. A maturação das funções relacionadas à resposta Th1 pelo uso de adjuvantes imunológicos no período pós-natal pode contribuir na profilaxia da asma e outras doenças alérgicas. Neste trabalho, investigamos o efeito dos oligodeoxinucleotídeos CpG na imunização com ovalbumina (OVA) e extrato do ácaro Blomia tropicalis (Bt) em camundongos nos períodos neonatal e adulto. Os resultados obtidos mostram que o ODN-CpG é capaz de diminuir a produção de anticorpos IgE, um isótipo dependente de citocinas Th2, e aumentar os níveis de anticorpos IgG2a nas imunização com OVA e Bt, inclusive na imunização com os dois alérgenos associados. Além disso, a associação do ODN-CpG na imunização neonatal com OVA promove um aumento da produção in vitro de IFN-<font face=\"symbol\">g e diminuiu a produção de IL-10. Ao compararmos a eficiência modulatória do CpG nas imunizações com OVA em camundongos adultos e neonatos, observamos um maior efeito modulatório na produção de anticorpos em adultos. Os resultados mostraram que linfócitos B de camundongos jovens não aumentam a expressão do TLR-9 mesmo após 72 horas de estímulo com CpG, enquanto nos linfócitos de adultos já é possível observar um aumento em 48 horas. Além da menor ativação dos linfócitos B, evidenciamos uma produção de IL-10 e MCP-1 significantemente aumentada na cultura de células de neonatos após estímulo in vitro com CpG. Ao avaliarmos a influência do CpG na ativação antígeno específica dos linfócitos T CD4+, mostramos que linfócitos T CD4+ de neonatos expressam mais intensamente moléculas B7 do que células de adultos após estímulo antigênico in vitro, o que sugere uma característica supressora nestas células. Esse aumento foi inibido pela adição de CpG na cultura. A indução de células Treg (CD4+CD25+Foxp3+) in vitro também foi suprimida pela adição de CpG. Nossos resultados mostram um potencial modulatório do CpG no período neonatal e adulto nas respostas a OVA e Bt. Evidenciamos, também, diferenças qualitativas e quantitativas no efeito do CpG em relação às imunizações neonatal e adulta. Considerando a suscetibilidade dos neonatos às infecções e ao desenvolvimento de alergia, torna-se importante estabelecer estratégias imunomodulatórias que potencializem as respostas inata e adaptativa e possam ser profiláticas no desenvolvimento de doenças alérgicas. / The allergy development may occur in the early life, during the pregnancy or postnatally at the first months of life. In mice, it is described a predisposition to Th2 biased response in the neonatal period, favoring the development of allergic response. The maturation of functions related to Th1 response by the use of immune adjuvants may be beneficial to the allergy prophylaxis. In this work, we evaluated the effect of CpGcontaining oligodeoxynucleotides (CpG-ODN) in the neonatal and adult immunization with ovalbumin (OVA) or the extract of house dust mite Blomia tropicalis (Bt). The results show CpG-ODN is able to decrease IgE antibody production, an isotype related to Th2 response, and increase IgG2a antibody levels in OVA or Bt immunization of A/Sn mice, even when mice were co-immunized with both allergens. Moreover, CpG-ODN association in neonate immunization with OVA increases in vitro IFN-<font face=\"symbol\">g production and decreases IL-10. Comparing the modulatory efficiency of CpG in OVA immunization of neonate and adult mice, we observed a stronger effect on antibody production in adults. Results show that B cells from young mice do not increase the TLR-9 expression upon CpG stimulation for 72 hours whereas the increase of TLR-9 in adult B cells occurs within 48 hours. Besides the lower B cell activation, we found a significant increase of IL-10 and MCP-1 secretion levels by the neonatal cells stimulated by CpG. When we evaluated the influence of CpG on CD4+ T cell activation upon antigenic stimulation, we verified an upregulation of B7 molecules expression on neonate cells than adult cells. This high expression was inhibited by the addition of CpG in the culture. The induction of regulatory T cells (CD4+CD25+Foxp3+) in vitro was also suppressed by CpG. Our results show a modulatory potential of CpG in the immune response to OVA and Bt in both neonatal and adult periods. We also evidenced qualitative and quantitative differences in the CpG effect between neonates and adults. Considering the susceptibility to infections and allergy development in newborns, it becomes important to establish immunomodulatory strategies that enhance innate and adaptive responses and are prophylactic to the development of allergic disorders.

Orientador: Maria Helena Baena de Moraes Lopes / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-04T09:55:03Z (GMT). No. of bitstreams: 1 Carmona_EleniceValentim_M.pdf: 8009687 bytes, checksum: d5480488c83d4f9d1af22d67c754372f (MD5) Previous issue date: 2005 / Resumo: o avanço na tecnologia da assistência médica e de enfermagem tem possibilitado a sobrevivência de muitos recém-nascidos prematuros e com outras complicações além de prematuridade. À medida que a equipe de saúde considera que o quadro clínico do bebê permite, a mãe passa a assumir grande parte dos seus cuidados. Assumir o papel materno pode não ser uma experiência fácil, devido às características situacionais e ambientais, nas quais o cuidado foi dado quase que predominantemente pela equipe de enfermagem. Assim, este estudo teve como objetivos: realizar validação de conteúdo do diagnóstico de enfermagem, proposto pela NANDA, "conflito no desempenho do papel de mãe" e suas características definidoras junto a enfermeiros que atuam em unidades de cuidados neonatais e pesquisadores da área; identificar as características definidoras maiores e menores deste diagnóstico e verificar se o julgamento dos enfermeiros foi influenciado por fatores como idade, tempo de atuação como enfermeiro, tempo de atuação em neonatologia, realização de cursos sobre diagnóstico de enfermagem, participação em cursos de pós-graduação, realização de pesquisa e utilização de diagnósticos. Acredita-se que este assunto torna-se de grande interesse porque o crescimento prático e teórico da enfermagem requer um maior domínio dos diagnósticos, como apresenta a literatura consultada, sendo a unidade de internação neonatal um local carente de estudos sobre este assunto. Foi utilizado o modelo de Validação de Conteúdo Diagnóstico proposto por FEHRING, o qual se baseia na obtenção de opiniões de enfermeiros (peritos, de acordo com os critérios deste modelo, seja por sua experiência assistencial, seja pelos estudos realizados) acerca do grau em que certas características definidoras são indicativas ou não de um determinado diagnóstico. A amostra utilizada neste estudo foi por conveniência, composta por 59 enfermeiros. O estudo validou as características definidoras estabelecidas pela NANDA para este diagnóstico. Quatro características definidoras foram consideradas maiores por terem obtido média ponderada maior ou igual a 0,80: 1. mãe expressa preocupação(ões)/ sentimento(s) de inadequação para suprir as necessidades físicas e emocionais da criança durante a hospitalização; 2. mãe expressa preocupação(ões)/sentimento(s) de inadequação para suprir as necessidades físicas e emocionais da criança em casa; 3. mãe expressa preocupação(ões) com relação a mudanças no papel materno e 4. mãe expressa preocupação(ões) em relação à saúde da família. As demais obtiveram média ponderada menor que 0,80, mas maiores que 0,50, sendo assim classificadas como menores. Nenhuma característica definidora foi excluída. Não houve correlação entre o perfil dos enfermeiros e o julgamento que fizeram das características definidoras. As dificuldades para a elaboração das definições operacionais e os comentários dos enfermeiros demonstraram o quanto as características definidoras propostas pela NANDA precisam ter sua linguagem reavaliada para que se tornem mais objetivas e descrevam melhor as respostas dos clientes frente aos problemas de saúde e processos de vida. Recomenda-se que a validação de conteúdo, seguida por validação clínica, se dê em diferentes culturas e locais de assistência para abranger as diversidades das clientelas atendidas / Abstract: The technological progress of medical and nursing assistance has made possible the survival of many newboms with medical complications. As the staff considers baby's condition is evolving well, the mother has more opportunity of taking care of him or her. To assume maternal role might not be an easy experience in the neonatal care unit due to the special characteristics of the situation and the environment and because of the mother's fragility, being distant from the child and taking care less often than the nursing staft. The aims of this study were: validating the content of the NANDA nursing diagnosis "Parental role conflict" and its defining characteristics, with nurses which work in neonatal care units and researchers of this area; identifying minor and major defining characteristics of this diagnosis and, finally, verifying if the scores attributed by nurses to the defining characteristics were influenced by factors as age, experience in nursing, time of neonatology practice, continuing education about nursing diagnoses, post-graduation, development of researches and the use of nursing diagnoses. This issue is really important because practical and professional nursing development require a greater domain of nursing diagnoses, according to literature, and neonatal care units are deprived of this kind of study. The diagnostic content validation model proposed by FEHRING was used in this work, which consists on obtaining opinion from nursing experts about how much certain defining characteristics are indicative or not of a diagnosis. It was a convenient sample of 59 nurses. It was recognized that the study validated the defining characteristics recognized by NANDA. Results showed that four defining characteristics were considered major because achieved scores of 0,80 and higher: 1. Mother expresses concem(s)/feeling(s) of inadequacy to provide for child's physical and emotional needs during hospitalization; 2. Mother expresses concem(s)/feeling(s) of inadequacy to provide for child's physical and emotional needs at home; 3. Mother expresses concem(s) about changes in parental role; 4. Mother expresses concem(s) about family health. No defining characteristic was eliminated. There was not correlation between nurses' profile and the judgement of the defining characteristics. The difficulties of operational definitions elaborating and the commentaries of nurses showed that the defining characteristics proposed by NANDA need assessment to become more objective and describe more accurately patients' answers concerning health problems and life issues. Recommend that a diagnostic content validation, followed by a clínical validation, happens in different settings of care and cultures to reach specific needs of clients / Mestrado / Enfermagem e Trabalho / Mestre em Enfermagem

M.Cur. / Neonates born with respiratory distress require supplementary oxygen. In some cases it is necessary to ventilate these neonates in order to obtain adequate tissue oxygenation. Due to the potential complications of mechanical ventilation it is necessary to extubate the neonate as soon as possible after intubation and administer supplementary oxygen by an alternate method. Any form of oxygen therapy carries the risk of oxygen toxicity. It is therefore essential that the method of oxygen therapy opted for after extubation will result in the infant being weaned in the shortest time possible. In the two NICUs from which the sample was taken for this study, neonates are currently extubated and placed either in a head box, on nasal CP AP or on a nasal cannula, these being the methods used to administer oxygen to a neonate. The decision regarding the method of choice is currently directed by customary practices rather than physiological variables as indicators/criteria of effectiveness. The questions that arise from the research problem are as follows: • Which physiological variables should be considered when faced with the decision regarding the method of oxygen therapy to initiate after extubation of a neonate? • Are there any differences in the effectiveness of the two methods of oxygen therapy, namely headbox and nasal cannula, after extubation of a neonate? The purpose of this study was to compare two methods of oxygen therapy, after extubation of the neonate with respiratory distress syndrome, in an attempt to formulate guidelines; based on physiological variables as criteria/indicators of effectiveness. After analyzing the data, as described in Chapter 4, it became evident that it would not be possible to formulate guidelines. Therefore only a comparison was done between the two methods of oxygen therapy (headbox and nasal cannula,) based on both biographical and physiological variables as criteria/indicators, to determine whether there were any significant differences in the effectiveness of the two methods after extubation of the neonate.

Předkládaná Diplomová práce se zabývá analýzou a tvorbou modelů dýchacích cest předčasně narozených dětí. Nejprve je položen teoretický základ v oblasti vývoje dýchacího ústrojí a tvorby modelů dýchacích cest. Poté jsou představeny využité zobrazovací modality a popsány metody pro práci s obrazovými daty. Praktická část práce se zabývá vytvořením modelů dýchacích cest tří novorozenců. Všechny tyto modely jsou vytvořeny na základě klinických CT a MRI dat novorozenců narozených ve 30. týdnu gestačního věku. U těchto vytvořených modelů jsou dále analyzovány vybrané parametry související s anatomickou strukturou dýchacích cest. Na základě analýzy těchto parametrů byl následně navrhnut reprezentativní model, odpovídající dýchacím cestám novorozence daného gestačního věku.

The topic of this master’s thesis is design of infant incubator. The thesis concerns own design of infant incubator that meet the basic technical, ergonomical and social requirements and also brings a new look and shape as solution to the main topic. The infant incubator is designed in regard to modern materials and technologies.

Eine Vielzahl von Faktoren können am Lebensanfang eine ausreichende Perfusion der Niere gefährden und ihre Funktion beeinträchtigen. Umgekehrt spiegelt eine suffiziente Nierendurchblutung meist auch eine stabile systemische Hämodynamik des Neugeborenen wieder. Laborwerte sind in diesem Alter wenig aussagefähig bezüglich der Nierenfunktion. Ziel dieser Studie war die Erstellung von dopplersonographischen Normalwerten der Blutflussparameter beim gesunden Neugeborenen am ersten und dritten Lebenstag. Es wurden Mittelwerte für die systolische, mittlere und diastolische arterielle Flussgeschwindigkeit in der A. renalis am ersten und dritten Lebenstag beim gesunden Neugeborenen durch dopplersonographische Messung bestimmt. Es konnten dopplersonographische Referenzparameter der Durchblutung der Niere ermittelt werden, die als unkompliziert messbare Parameter in der neonatologischen Praxis zur Einschätzung systemisch hämodynamischer Veränderungen sowie funktioneller Störungen der Niere bis zum akuten Nierenversagen benutzt werden können.

This dissertation consists of three essays in health economics, paying special attention to neonatal care provision and newborn health outcomes in the United States. The first chapter evaluates physician productivity, focusing on the matching between physician skills and patient conditions. High U.S. spending on health care is commonly attributed to its intensity of specialized, high-tech medical care. A growing body of research focuses on physicians whose medical decisions shape treatment intensity, costs, and patient outcomes. Often overlooked in this research is the assignment of physician skills to patient conditions, which may strongly affect health outcomes and productivity. This matching may be especially important in the case of hospital admissions as high-frequency fluctuations in patient flow make it challenging to maintain effective matches between the best-suited physicians and their patients. This paper focuses on hospitals’ responses to demand shocks induced by unscheduled high-risk admissions. I show that these demand shocks result in physician–patient mismatches when hospitals are congested. Specifically, highly specialized physicians who are brought in to treat unscheduled high-risk admissions also treat previously admitted lower-risk patients. This leads to increased treatment intensity for lower-risk patients, which I attribute to persistence in physician practice style. Despite the greater treatment intensity, I find no detectable improvement in health outcomes, which prima facie could be viewed as waste. However, the mismatches observed only at high congestion levels more likely reflect hospitals’ careful assessment of costs and benefits when assigning physicians to patients – maintaining preferred physician–patient matching can be particularly costly when congestion is high. My findings highlight the need to consider both heterogeneity within patient and physician type, and furthermore show how the common phenomenon of demand uncertainty can promote mismatch between these types. The second chapter assesses hospital self-reported facility data quality using annual Institutional Cost Report (ICR). In the United States, hospital facilities are under public and government supervision. The central motivation behind this is that overbuilding and redundancy in health care facilities will lead to overutilization and higher health care costs. However, little is known about the effectiveness of these facility regulation policies. Taking certified capacities recorded by the Department of Health as reliable benchmarks, this paper presents evidence that hospitals upcode their neonatal intensive care unit (NICU) bed levels when reporting capacities in ICR. Reported NICU utilization in ICR is mostly under the top level NICU bed, which matches the bed capacity upcoding pattern. This indicates either significant overutilization which leads to NICU overcrowding, or upcoding in medical billing that results in inflated medical charges. Findings in this paper point to a potentially effective way for regulators and insurers to limit overutilization – improving hospitals’ compliance with their certified capacities. This paper also provides important guidelines for a large body of research that uses ICR data by developing an assessment of ICR data quality. The third chapter, which is joint work with Douglas Almond, measures gender inequality in perinatal health among Chinese-American newborns. The literature on “missing girls" suggests a net preference for sons both in China and among Chinese immigrants to the West. Perhaps surprisingly, we find that newborn Chinese-American girls are treated more intensively in US hospitals: they are kept longer following delivery, have more medical procedures performed, and have more hospital charges than predicted (by the non-Chinese gender difference). What might explain more aggressive medical treatment? We posit that hospitals are responding to worse health at birth of Chinese-American girls. We document higher rates of low birth weight, congenital anomalies, maternal hypertension, and lower APGAR scores among Chinese American girls – outcomes recorded prior to intensive neonatal medical care and relative to the non-Chinese gender gap. To the best of our knowledge, we are the first to find that son preference may also compromise “survivor" health at birth. On net, compromised newborn health seems to outweigh the benefit of more aggressive neonatal hospital care for girls. Relative to non-Chinese gender differences, death on the first day of life and in the post-neonatal period is more common among Chinese-American girls, i.e. later than sex selection is typically believed to occur.

Background. Premature infants are at risk for many complications. Among these, growth failure and intermittent hypoxia (IH) can independently impact the outcomes of other comorbidities. Recent data suggest that IH may directly affect postnatal growth. Our study aims to evaluate the impact of IH on growth velocity in preterm infants. Methods. This prospective cohort study utilized inpatient oximetry, nutrition, and growth data to evaluate the relationship between IH and growth velocity. Enrolled infants were dichotomized by high- versus low-exposure to IH. This relationship was explored in both unadjusted analyses and generalized linear models with repeated measures. Results. The study population included 19 preterm infants, with average birth gestational age of 29 weeks, each contributing one or more measures of weekly data. Infants in the high-exposure cohort had lower birth weight, higher rates of bronchopulmonary dysplasia, and longer duration of respiratory support and caffeine treatment. The unadjusted analysis revealed a marginally significant trend towards higher IH rates during weeks of slower growth. The logistic regression with repeated measures analysis also supported increased odds of slower growth associated with higher IH rates, but this relationship was also only marginally significant. Conclusion. Our study suggests a relationship between exposure to IH and slower growth velocity in preterm infants. The prospectively collected data allowed for accurate measures of IH, growth, and nutrition, but the small sample size likely contributed to the lack of significance of our results.

BACKGROUND: Neurodevelopment and growth are primary concerns when neonates are born extremely premature (between 23 and 28 weeks gestation). The focus of the PENUT Trial is to administer erythropoietin (Epo) to extremely preterm infants and to study the potential neuroprotective effects of Epo. The PENUT ethics survey was designed to provide study investigators with parental feedback regarding the consent process for the PENUT Trial and to improve the consent process for future research trials. OBJECTIVES: The objectives of this research thesis are to learn (1) what factors are important to parents who are approached for informed consent to include their infants in a research study and (2) how parents may be influenced by demographic and social factors. The hypothesis is that parents approached prenatally may be more likely to consider enrolling their infants into the PENUT Trial. METHODS: All parents approached to enroll their eligible infants into the PENUT Trial (both consenting and non-consenting parents) were eligible to complete the ethics survey. While completing the survey, parents (1) responded to statements about factors involved in their decision-making process, (2) rated their overall experiences in being asked to join the PENUT Trial, (3) described what ultimately led them to enroll or not to enroll their infants in the PENUT Trial, and (4) responded to demographic questions. RESULTS: Thirty mothers of infants eligible for the PENUT Trial (22 consenting, 8 non-consenting) were approached by a research study coordinator to complete the survey. Of the 22 consenting mothers, 10 were approached prenatally, and 12 were approached postnatally for the PENUT Trial. However, of the 8 non-consenting mothers, only 1 was approached prenatally, whereas 7 were approached postnatally for the PENUT Trial. The ethics survey was completed by 20 of 22 consenting mothers and 6 of 8 non-consenting mothers. The average rating among mothers of their overall experiences with the consenting process for the PENUT Trial was 3.77 (2.75 among non-consenters, 4.00 among consenters) on a scale of 1 (= poor) to 5 (= excellent). Thirteen mothers preferred to be approached for the PENUT Trial by their baby’s neonatologist (6 preferred their OB/GYN, 5 preferred another doctor, 1 preferred a study coordinator, and 10 had no preference). In addition, 14 mothers preferred that the person approaching them was involved in the research trial (5 preferred person not involved, 2 preferred to be approached by those involved and not involved, and 9 had no preference). Lastly, 18 mothers preferred to be approached prenatally (5 postnatally, and 7 had no preference). CONCLUSIONS: Preliminary findings from the PENUT Trial ethics survey support the hypothesis that mothers prefer to be approached prenatally when considering enrollment of their newborn infants into the PENUT Trial. Survey responses also suggest that during the consent process mothers prefer to be approached by either (1) two neonatologists, with one responsible for the baby’s care and the other responsible for the research trial, or (2) one neonatologist who is involved in both the baby’s care and the research trial.

Yes / perinatal palliative care services are increasingly available globally, offering a range of clinical and psychological support services to families during pregnancy, in the neonatal period and following the death of a baby with a life-limiting or life-threatening condition. Little is understood about the role of children’s hospice care and how it contributes to effective perinatal palliative care. Design: The study aims to answer the question ‘what is the role of children’s hospices in the provision of perinatal palliative care and advance care planning in the United Kingdom?’ Methods: An electronic survey was sent to all 54 children’s hospices in the United Kingdom between May and June 2022. Results: 30 hospices responded, representing 54% of the sector. All regions of all four counties are represented. Numbers of referrals to hospices for perinatal palliative care have increased significantly over the last five years. Hospices provide a range of services for families and babies, usually from the point of diagnosis or recognition of a life-limiting or life-threatening condition, underpinned with counselling and emotional support. Hospices worked with a range of professionals and services, most commonly fetal medicine and neonatal services. Advance care plans were an important element of effective perinatal palliative care, strengthening parent-professional and interprofessional relationships. Conclusion: Children’s hospice services play an important and growing role in the perinatal care of babies and families following the diagnosis or recognition of a life limiting or life-threatening condition. The family centred approach to care, from a broad, biopsychosocial perspective means that hospices make a unique and meaningful contribution to both the clinical and psychological needs of families. / University of Bradford. Grant Number: DA5151. SURE Research Project