Made available in DSpace on 2014-06-12T23:02:12Z (GMT). No. of bitstreams: 2 arquivo9047_1.pdf: 1637307 bytes, checksum: f62840bbf4343e1158be0160291245d7 (MD5) license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) Previous issue date: 2012 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Os períodos pré e pós-natal representam a fase de maior desenvolvimento neuronal. Nessa fase crítica do desenvolvimento, o organismo é suscetível às influências de estímulos ambientais que podem modular os eventos ontogenéticos posteriores promovendo sérias consequências na vida adulta. Dentre esses estímulos ambientais, a desnutrição e o tratamento com inibidores seletivos da receptação de serotonina (ISRS) estão associados a vários prejuízos morfofuncionais na vida adulta. Algumas regiões encefálicas responsáveis pela manutenção do balanço energético são alvos de ajustes permanentes promovidos por desnutrição ou ISRS no período perinatal. Nesse estudo, o objetivo foi investigar no núcleo do trato solitário (NTS) os efeitos da desnutrição ou tratamento com ISRS durante os estágios inicias do desenvolvimento sobre o controle da ingestão alimentar. Foram utilizados ratos da linhagem Wistar distribuídos aleatoriamente nos grupos Controle e Desnutrido formados por animais cujas mães receberam durante a gestação e lactação dieta contendo 17% ou 8% de caseína respectivamente. Dois outros grupos foram formados de acordo com tratamento farmacológico durante a lactação. Estes foram os grupos Salina e Fluoxetina, compostos por filhotes que receberam, respectivamente, solução de salina (NaCl 0.9%,) ou Fluoxetina (10mg/Kg) via subcutânea, diariamente, do 1º ao 21º dia de vida. Foram avaliados aos 35 e 180 dias de vida: a) Peso corporal; b) Ingestão Alimentar; c) Expressão da proteína FOS por imunohistoquímica no NTS em resposta a estímulo alimentar. As áreas estudadas foram identificadas e os neurônios imunorreativos quantificados através do microscópio ótico de campo claro com auxilio do atlas estereotáxico de Paxinos e Watson (1998). Com base nessas avaliações, o presente trabalho demonstrou que: a) a desnutrição perinatal promoveu aumento no consumo alimentar e número de células ativadas nas porções rostral (Controle= 166,3±33,8 vs Desnutrido=297,8±33, P=0.028) e medial (Controle= 167,8±47,44 vs Desnutrido=291,2±28,3, P=0.0043) do NTS em resposta a estímulo alimentar apenas em animais com 35 dias de vida; b) o tratamento neonatal com fluoxetina promoveu aumento no número de neurônios ativados em resposta a estímulo alimentar na porção rostral (Salina= 218,3±6,6; Fluoxetina=367±25,9, P=0.005) de animais adultos (180 dias); Estes resultados indicam que o NTS é uma estrutura particularmente vulnerável as influências da manipulação nutricional e farmacológica do sistema serotoninérgico nos estágios iniciais do desenvolvimento, e pode ser alvo de processos adaptativos do controle do balanço energético observados nesses animais na vida adulta

Made available in DSpace on 2014-06-12T23:02:56Z (GMT). No. of bitstreams: 2 arquivo4379_1.pdf: 3547847 bytes, checksum: b0e6edcc3df9548b70ac1f498ac7b288 (MD5) license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) Previous issue date: 2008 / Objetivo: Avaliar os efeitos da desnutrição durante a lactação sobre a morfologia da laringe de ratos aos 22 e 60 dias de idade. Métodos: Ratos albinos machos da linhagem Wistar (n=48) foram divididos em dois grupos de acordo com a dieta das mães durante a lactação: controle (caseína 17%) e desnutrido (caseína 8%). Após o desmame, todos os animais receberam dieta padrão do biotério. Metade dos animais de cada grupo foi sacrificada aos 22 dias de vida, e a outra metade aos 60 dias de vida. A desnutrição neonatal foi diagnosticada através do peso corporal avaliado diariamente ao longo do experimento, sendo calculado o ganho de peso corporal e a taxa de crescimento. Após o sacrifício, a laringe foi retirada e suas dimensões registradas com paquímetro digital de acurácia 0,01 mm. Foram avaliados os comprimentos da laringe: epiglote a cricóide (EC), tireóide a cricóide (TC), antero-posterior (AP) e latero-lateral (LL). Para a análise histológica foi utilizada a coloração hematoxilina-eosina. A laringe foi analisada qualitativamente, subdividida em supraglote, glote e infraglote. As pregas vocais também foram analisadas quanto às dimensões do epitélio, o núcleo e suas camadas, através do programa Scion Image, Beta 4.0.2. Resultados: Os animais cujas mães foram desnutridas durante a lactação apresentaram redução do peso corporal, diminuição do ganho de peso corporal durante a lactação que aumentou durante a recuperação nutricional (p<0.05). A taxa de crescimento reduziu (p<0.05) no período neonatal se normalizando na recuperação nutricional comparativamente ao controle. Quanto a macroscopia da laringe, os animais aos 22 dias apresentaram uma diminuição nas dimensões ântero-posterior e látero-lateral comparativamente ao controle (p<0.05). Aos 60 dias de idade, não houve diferença entre os grupos nas variáveis analisadas. Na análise microscópica houve um aumento da queratinização do epitélio da supraglote, aos 22 e 60 dias de vida nos animais desnutridos. Na prega vocal houve redução do comprimento do epitélio, do diâmetro do seu núcleo e da camada intermediária nos animais desnutridos no período neonatal aos 60 dias de vida. Conclusão: A desnutrição neonatal induziu alterações nas micro-estruturas da laringe dos animais desnutridos, mesmo após a recuperação nutricional. A macro estrutura sofre os efeitos imediatos da restrição nutricional diminuindo as dimensões horizontais da laringe com recuperação a longo-prazo. Nossos resultados indicam que a escassez de nutrientes durante o período crítico de desenvolvimento induz alterações na morfologia da laringe a curto e em longo prazo. Estudos que avaliem a função desse órgão são necessários

Neonatal sepsis is an important cause of neonatal morbidity and mortality. There are two distinct types of sepsis- early and late onset. Group B streptococcus and Listeria are the most common causes of early onset neonatal sepsis historically. Physicians select antibiotics for neonates with fever based on historically common bacterial pathogens such as GBS, Ecoli, Listeria, and Staphylococcal aureus. However, the landscape of bacterial pathogens causing sepsis and fever in neonates seems to be changing. This could potentially change the first choice of antibiotics for this susceptible population. In this case study, we will present early-onset sepsis in a late preterm infant due to Streptococcus pneumoniae as confirmed by blood culture. The only maternal risk factors present in this case for septicemia were delivery less than 37 weeks. Patient initially had respiratory distress at delivery and required CPAP for 3 days. On day 2 of life, cultures were taken due to acute deterioration. Ampicillin and Gentamycin were given to the patient for empiric coverage initially. On day 2 of antibiotics, cultures were reported positive. Patient’s antibiotics had to be altered at that time to cover the isolated organism. The patient was inadequately treated up until cultures were positive. This case raises the question if Ampicillin and Gentamycin remain the best choice for broad antibiotic coverage in neonates with possible sepsis.

Introduction: The prevalence of opioid abuse has increased throughout Northeast Tennessee. Subsequently, more infants are born drug-exposed or with Neonatal Abstinence Syndrome (NAS). According to the Tennessee Department of Health, hospitalizations for deliveries with maternal substance abuse tripled in Tennessee between 1999 and 2011. During this period, the inpatient hospitalization rate for NAS increased 11-fold. In 2017, there were 163 NAS cases reported in Northeast Tennessee. Depending on intrauterine and environmental exposures, there may be differences in health, growth, behavior, and development in infants. Our goal was to assess and explore those differences to help update education and care recommendations for pediatric primary care clinics. Methods: This cross-sectional study was set in a Northeast Tennessee pediatric clinic. 120 patients seen for a newborn visit between June 30, 2013 and July 1, 2014 were randomly selected. An additional sample of all infants with suspected drug exposure was identified for this period based on diagnosis codes. In total, 99 infants had no drug exposure and 62 were drug-exposed. An 83-item chart abstraction template was developed. Data was analyzed by SPSS. The chi-squared test and Mann-Whitney U test were used, with a critical value of p<0.05 to determine significance. The Bonferroni correction was applied to account for multiple comparisons. The research protocol was reviewed and approved by the Institutional Review Board of East Tennessee State University. Results: Of the 120 charts initially selected, 3.33% of infants were exposed to buprenorphine, 1.67% to methadone, 0.83% to marijuana, 0.83% to cocaine, and 1.67% to tobacco, 8.33% to benzodiazepine, and 1.67% to barbiturates during gestation. In total, 18.33% of infants had any drug exposure, 10.00% to any opiate, and 3.33% had a documented diagnosis of NAS in their chart. Prenatal drug exposure was significantly associated with multiple demographic factors as well as pediatric respiratory, behavioral, gastrointestinal, infectious disease, and cardiac conditions. Conclusions: Prenatal drug exposure was significantly associated with multiple pediatric complications. This illustrates the significance of addressing the increased incidence of prenatal drug exposure in Northeast Tennessee. Future multivariate analyses will attempt to control for potential confounders. This analysis is retrospective and exploratory, and any associations should be confirmed with a prospective study. A weakness of this study includes potential under-diagnosis of drug exposure and NAS due to lack of documentation in the EHR. Additional research will include further comparison of maternal and infant complications in drug-exposed and non-exposed infants. This will allow for a better understanding of the risks associated with maternal drug exposure. Findings from these research projects will be used to inform clinical initiatives for NAS in Northeast Tennessee.

Bakgrund: Det nyfödda barnet är en patient som är särskilt känslig för förändringar i kroppstemperaturen och risken är stor för både hypotermi och hypertermi. För att undvika ökad risk för sjuklighet och dödlighet är det därför viktigt att det nyfödda barnets kroppstemperaturen hålls inom gränserna 36,5–37,5 ℃. Detta är en utmaning inom neonatalvården och utmaningen blir större i och med sjunkande gestationsålder och födelsevikt. Motiv: Att med hitta en fungerande metod för beröringsfri temperaturmätning så att barnet ej störs vid kontroll av kroppstemperaturen. Syfte: Attstudera överensstämmelsen mellan beröringsfri infraröd termometer och två vedertagna metoder, axill- och rektalmätning av kroppstemperatur på nyfödda barn som vårdas på en neonatal intensivvårdsavdelning. Syftet var också att studera om överenstämmelsen mellan metoderna skiljer sig om barnet vårdas i kuvös, öppenvårdskuvös eller säng.Design: En prospektiv studie med upprepade mätningar. Metod: 35 barn inkluderades i studien och temperaturmätningar genomfördes vid tre mättillfällen med de tre olika metoderna. Datan analyserades enligt Bland-Altmans analysmetod för att bedöma överensstämmelse mellan kliniska mätmetoder. Resultat: Denna studie visade att det fanns överensstämmelsen mellan infraröd mätning och axillmätning, men att dess 95%-iga konfidensintervall var för vida för att kunna accepteras i klinisk praxis. Överensstämmelse mellan infraröd- och rektaltemperaturmätning samt mellan axill- och rektaltemperaturmätning kunde inte påvisas. Konklusion: Kroppstemperaturmätning med beröringsfri infraröd termometer är en tilltalande metod för temperaturmätning hos nyfödda barn med tanke på dess fördelar. Metodutveckling och mer forskning med större urval krävs dock för att användning av infraröd temperaturmätning inom neonatal intensivvård ska kunna etableras.

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Antimicrobials are the most frequently used medications in the Neonatal Intensive Care Unit (NICU). Antimicrobial Stewardship (AMS) efforts may be used to mitigate the consequences of antimicrobial overuse while optimizing clinical outcomes through the safe, judicious use of antimicrobials. One target of AMS efforts is to reduce the incidence of necrotizing enterocolitis (NEC), a serious intestinal infection in neonates of which a necessary component is dysbiosis, the development of aberrant intestinal microbiota typically associated with prior antibiotic use. The goal of this ILE is to implement and enhance AMS efforts in the neonatal population with a focus on preventing NEC. The specific aims progress through three relevant, practical examples of AMS in a stepwise manner. Methods: In Aim 1, a systematic review of the literature evaluating the relationship between antimicrobial therapy and subsequent development of NEC and a meta-analysis including non-interventional studies was performed. Data were pooled on adjusted odds ratios (OR) and analyzed using the generic inverse variance method. All analyses were random effects models. A sensitivity analysis was performed based on a range (0-40%) of credibility ceilings. In Aim 2, institutional guidelines for early and late onset neonatal sepsis using the principles of AMS and the evidence for safe restriction of antimicrobials targeted for reduction in use in neonates by the National Healthcare Safety Network (NHSN) were created and implemented . In Aim 3, a reproducible 2-class latent variable model to extract a date-stamped diagnosis of NEC from the Pediatric Health Information System (PHIS) database was created as a tool to enhance research evaluating antibiotic use and NEC from large databases. This model was created using a subset of infants at two PHIS sites that were able to be validated. M plus software was used. Conclusions: For Aim 1, 36 studies met inclusion criteria for the systematic review, with 33 proceeding to quantitative analysis. There were 10 RCTs, the remaining being observational studies. Using the ROBINS-I or RoB 2.0 tools as appropriate, all studies including the RCTs had a least a moderate or high risk of bias respectively. The overall analysis failed to provide evidence of an association between prior antimicrobial use and NEC when all 33 studies were included, with a summary OR of 1.13, CI95 (0.88, 1.45) and significant heterogeneity, I2 = 77%. Multiple subgroup analyses were performed: “intent” of antibiotic use (prophylaxis versus not) drug delivery method (oral versus parenteral) and study type. Subgroup analysis of prophylactic enteral antibiotics showed a reduction in NEC: OR 0.2 CI95 (0.08, 0.54), I2 = 35% while prior use of parental antibiotics showed a positive association with NEC OR 1.48, CI95 (1.18, 1.86), I2 72%; for this subgroup, using a c% shows heterogeneity first reaching an estimate of 0% at a ceiling of 10% with nominal statistical significance is maintained starting at a ceiling of 10%. This shows that consideration of the biologic mechanism of the exposure-disease association, as indicated by the subgroup analyses in this study, must be considered when performing further dataset evaluations lest biased conclusions will be reached. For Aim 2, Four guidelines were created and implemented and are being validated: • The evaluation and management of infants ≥ 35 weeks gestational age at risk for early onset sepsis at Tufts Medical Center • The evaluation and management of infants ≥ 36 weeks gestational age at risk for early onset sepsis at BronxCare Hospital Center • The evaluation and management of infants < 36 weeks gestational age at risk for early onset sepsis at BronxCare Hospital Center • The evaluation and management of infants at risk for late onset sepsis at BronxCare Hospital Center For Aim 3 a model was successfully created that can be used to add an important layer of detail, time-of-event, to patient level variables in a large data set. This model can also be used to tabulate the sensitivity of a disease in the absence of a gold standard. The model is portable and could serve as a template for the PHIS or other large databases where certain important exposures may not be date stamped. The model may be adapted to not only allow for appropriate extraction of variables, but also allow the correct modelling of time-dependent co-variables.

faustino.perez@unizar.es / Objective: To assess the effects of vitamin D supplementation during pregnancy on obstetric outcomes and birth variables. Design: Systematic review and meta-analysis of randomized controlled trials (RCTs). Setting: Not applicable. Patient(s): Pregnant women and neonates. Intervention(s): PubMed and 5 other research databases were searched through March 2014 for RCTs evaluating vitamin D supplementation calcium/vitamins/ferrous sulfate vs. a control (placebo or active) during pregnancy. Main Outcome Measure(s): Measures were: circulating 25-hydroxyvitamin D [25(OH)D] levels, preeclampsia, gestational diabetes mellitus (GDM), small for gestational age (SGA), low birth weight, preterm birth, birth weight, birth length, cesarean section. Mantel-Haenszel fixed-effects models were used, owing to expected scarcity of outcomes. Effects were reported as relative risks and their 95% confidence intervals (CIs). Result(s): Thirteen RCTs (n ¼ 2,299) were selected. Circulating 25(OH)D levels were significantly higher at term, compared with the control group (mean difference: 66.5 nmol/L, 95% CI 66.2–66.7). Birth weight and birth length were significantly greater for neonates in the vitamin D group; mean difference: 107.6 g (95% CI 59.9–155.3 g) and 0.3 cm (95% CI 0.10–0.41 cm), respectively. Incidence of preeclampsia, GDM, SGA, low birth weight, preterm birth, and cesarean section were not influenced by vitamin D supplementation. Across RCTs, the doses and types of vitamin D supplements, gestational age at first administration, and outcomes were heterogeneous. Conclusion(s): Vitamin D supplementation during pregnancy was associated with increased circulating 25(OH)D levels, birth weight, and birth length, and was not associated with other maternal and neonatal outcomes. Larger, better-designed RCTs evaluating clinically relevant outcomes are necessary to reach a definitive conclusion. (Fertil Steril 2015;-:-–-. 2015 by American Society for Reproductive Medicine.) / Revisión por pares

Background: The prevalence of neonatal dysphagia is increasing, as medical advances contribute to the survival of critically ill and preterm infants. Additional factors such as low birth weight (LBW), gastroesoephageal reflux disorder (GERD), failure to thrive (FTT) and exposure to HIV may increase the complexity of dysphagia symptoms. Knowledge of context-specific risk factors for dysphagia in the neonatal intensive care unit (NICU) may lead to an effective pathway of diagnosis and management in vulnerable neonates. Objective: The objective was to describe the feeding characteristics and categories of underlying medical conditions in 24 to 42 week gestational age infants while still in the NICU and who were referred for feeding and swallowing assessment. Method: The study was a retrospective investigation of 231 purposively selected medical and speech-language therapy records. Participants had a mean stay of 28.5 days in the NICU of a peri-urban public hospital and all had feeding concerns. An existing seven-category framework for the classification of suspected dysphagia was used. Results: Feeding characteristics of the participants demonstrated that 65.0% had previous enteral tube (NGT/OGT) feeding, and only 15.6% were referred for instrumental assessments such as a VFSS by doctors or speech-language therapists (SLTs). The majority of participants used a mixed manner of feeding such as cup and breastfeeding, or cup and syringe feeding. Only 29.7% of participants was able to breastfeed exclusively which was an indication of feeding difficulties as the hospital where the study was conducted promotes exclusive breastfeeding. Results indicated that the majority of participants (90.04%) presented with multiple medical conditions. Underlying neurological conditions (48.48%) and feeding difficulties secondary to systemic illness (65.80%) contributed mostly to suspected dysphagia in the sample. It was found that 70.99% of infants presented with feeding difficulties secondary to other conditions such as LBW and prematurity, highlighting the need for an expanded dysphagia classification framework. Conclusion: The results are in agreement with the outcomes of previous research and confirm the need for a unique classification framework for dysphagia in South Africa. Neonatal dysphagia is a complex condition and frequently associated with multiple risk factors. / Dissertation (M Communication Pathology)--University of Pretoria, 2016. / Speech-Language Pathology and Audiology / MCommunication Pathology / Unrestricted

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