Academic literature on the topic 'Premature morbidity'

The article presents the analysis of the health status of children born prematurely during the first year of their life. There is the comparison of morbidity rates for five years of the operation of the catamnesis center of Kazan. Profoundly premature children demonstrated the highest level of morbidity with more frequent pathologies of the central nervous system, respiratory organs, eyes and anemia of premature children. In 2017 there was a decrease in the frequency and severity of respiratory diseases (bronchopulmonary dysplasia with chronic respiratory insufficiency 1.6 times), the nervous system (severe ischemic and hypoxic-hemorrhagic lesions of CNS 2.7 times), eyes and its adnexa (a complicated retinopathy of premature children 1.7 times) in extremely premature infants.

Premature birth is an important public health problem associated with increased perinatal morbidity and mortality rates. Due to the triggering mechanisms of premature birth as well as the immaturity of the fetal brain, it is more prone to injury. Thus, these premature babies have an increased risk of immediate neurological complications as well as late neurodevelopmental abnormalities, which can have lifelong repercussions. Prompt identification of fetal brain injury and their treatment, as well as the supervision at regular time intervals of the neurodevelopment of children born prematurely, are a real challenge for the medical system.

Infant mortality is a major problem in developing countries and, unfortunately, this is the case of our country as well, given that Romania ranks first in the European Union in this respect, with an infant mortality rate of 9 ‰, compared to an average of roughly 4 ‰. Worldwide, over 15 million babies are born prematurely each year and, out of these, more than a million die due to prematurity and infections, which are the main risk factors for neonatal mortality. The risk of infection is several times higher in preterm newborns than in full-term newborns – about 80% of neonatal infections occur in premature infants. A significant proportion of the survivors of prematurity will have important neurological sequelae because of neonatal infections as well as of intracerebral bleeding or hypoxia at birth. Continuing medical education in both the general population and the medical sector is crucial in preventing premature births and neonatal infections and, consequently, in decreasing infant morbidity and mortality rates in our country.

Premature was the main cause of 60-80% neonatal morbidity and mortality worldwide. Hemoglobin (Hb) and low nutritional status in pregnant women was one of the factors that can affect preterm labor. This study aims to determine differences in hemoglobin levels and nutritional status in normal and premature birth in Abdoer Rahem Situbondo hospital. The design used a comparative analitic with cross sectional approach. The study population was normal and premature delivery was 68 mothers. The sampling method used total sampling with 68 respondents samples, data collection technique with medical record and implemented in 2015. The results showed that there wa difference in Hb level and nutritional status in normal and premature labor. Chi-Square test results showed P-value = 0,000> 0.05 then H0 was ignored. So it can be concluded that there was a difference between hemoglobin levels and nutritional status in normal and premature labor. Keywords : Pregnant Women, Hemoglobin Levels, Nutritional Status. ABSTRAK Prematur merupakan penyebab utama 60-80% morbiditas dan mortalitas neonatal di seluruh dunia. Hemoglobin (Hb) dan status gizi yang rendah pada ibu hamil salah satu faktor yang dapat mempengaruhi persalinan prematur. Penelitian ini bertujuan untuk mengetahui perbedaan kadar hemoglobin dan status gizi di normal dan kelahiran prematur di rumah sakit Abdoer Rahem Situbondo. Desainnya adalah analitik komparatif dengan pendekatan cross sectional. Populasi penelitian adalah normal dan prematur ibu melahirkan adalah 68 ibu. Metode sampling yang digunakan adalah total sampling dengan sampel 68 responden, teknik pengumpulan data pengambilan dengan rekam medis dan dilaksanakan pada tahun 2015. Hasil penelitian menunjukkan tidak ada perbedaan dalam tingkat Hb dan status gizi di persalinan normal dan prematur. Hasil uji Chi-Square menunjukkan bahwa hasil dari Pvalue = 0,000> 0,05 maka H0 ditolak. Jadi dapat disimpulkan bahwa ada perbedaan antara kadar hemoglobin dan status gizi di persalinan normal dan prematur. Kata kunci : Wanita Hamil, Kadar Hemoglobin, Status Gizi.

We revised a neonatal morbidity scale (the NMS) that has served as a means for comparison of neonatal illness in studies of high-risk neonates after initial hospital discharge. With an inception cohort approach, 89 premature infants at an urban university hospital were studied with the expanded scale (the ENMS). The original scale, published in 1983, was reworked and expanded based on advances in the diagnosis and management of neonates. A social risk scale was added. Linear and logistic regression analyses were used to judge validity of the newly revised scale and to examine its predictive ability for outcomes at six months of age. Concurrent validity was supported by the relationship between the ENMS-SRS and: birthweight (R2 = .54), gestational age (R2 = .50), length of stay (R2 = .47). Inter-rater reliability was .95. The ENMS, embodying a contemporary patient profile, is valid for a population of premature infants in a U.S. urban setting and has predictive validity for a few outcomes within six months of discharge from a special care unit.

EACH YEAR APPROXIMATELY 460,000 infants—nearly 12 percent of all babies born in the U.S.—are born prematurely.1 Technological advances in the medical and nursing care of premature infants over the past decade have increased survival rates among preterm newborns, especially of very low birth weight (VLBW) infants. Survival rates are as high as 49 percent for infants weighing 501–750 gm at birth, 85 percent for infants weighing 751–1,000 gm, 93 percent for infants weighing 1,001–1,250 gm, and 96 percent for infants weighing 1,251–1,500 gm.2 Although 50–60 percent of VLBW infants have normal outcomes, morbidity rates range from 40 to 50 percent.3 Because of this incidence of morbidity, premature infants require comprehensive primary care follow-up after discharge from the NICU.

Due to increased use of ART delayed twin interval delivery has become a common occurrence. Multiple pregnancy is associated with high incidence of premature labour. Prematurity is the leading cause of neonatal morbidity and mortality all over the world as premature babies are at a greater risk of dying and has other health issues. Delivery of the presenting fetus usually followed by delivery of the second fetus shortly thereafter. There is no study available for the management of multifetal pregnancy, where one twin had delivered very prematurely and the time interval of the delivery for subsequent fetus. Conservation of pregnancy has good outcome when properly managed with careful surveillance. Survival rate increases by approximately 10% every week conserved in utero. Reservation persist in anticipation of increased maternal morbidity and mortality due to infection after conservative management.Time interval remains a dilemma in extreme prematurity.

Humidifying infant incubators facilitates heat retention, but entails an infection risk from microbial humidifier contamination. The Royal Victoria Hospital nursery was recently reequipped with steam humidity source incubators and converted to incubator humidification. An observational (before-after) study investigated the association between incubator humidification and hypernatremia and (secondarily) other hydration associated outcomes in very premature infants.
Thirty-one incubator humidification and 60 non-humidification period infants were compared. Mean gestational age was 25.83 weeks for both groups. Mean highest serum sodium values were 143.5 (SD 9.4) and 152.9 (SD 4.9) mEq/l respectively (p < 0.001). Differences persisted after adjustment for confounding by age of placement in incubators, and in spite of fluid reduction in the D humidification period. Of infants with umbilical lines 2/16 and 33155 respectively attained serum potassium measurements over 6.9 mEq/l (p = .04). Overhydration outcomes did not differ, but power was limited and confounding was problematic for these analyses.
In summary, incubator humidification is associated with decreased hypernatremia and hyperkalemia in very premature infants.

Orientador: José Guilherme Cecatti
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
Made available in DSpace on 2018-08-26T18:48:20Z (GMT). No. of bitstreams: 1 Souza_RenatoTeixeira_M.pdf: 10640708 bytes, checksum: 93bc984ddc636a415fed23ea6ca3a333 (MD5) Previous issue date: 2015
Resumo: Introdução: Mais de 15 milhões de bebês nascem prematuros anualmente no mundo, sendo a prematuridade a maior causa de óbitos no período neonatal. A prematuridade terapêutica tem papel importante nesse contexto, pois se estima que 20 a 40% dos partos prematuros ocorrem por indicação dos provedores de assistência obstétrica. Dessa forma, a redução dos partos prematuros terapêuticos adquire cada vez mais importância para o controle da taxa de prematuridade e da morbimortalidade neonatais. O conhecimento dos fatores relacionados ao parto prematuro terapêutico é ponto fundamental para atingir essa redução. Objetivos: Avaliar a ocorrência do parto prematuro terapêutico e seus fatores associados na população do Estudo Multicêntrico de Investigação em Prematuridade (EMIP). Métodos: Análise secundária do EMIP, um estudo brasileiro de caso-controle aninhado a um corte transversal multicêntrico. O estudo ocorreu em 20 hospitais de referência em 3 regiões do Brasil de abril de 2011 a julho de 2012 e realizou a vigilância de 33.740 partos nesse período. O principal desfecho a ser avaliado é a ocorrência de parto prematuro terapêutico, definido como o parto que ocorreu antes de 37 semanas e que foi indicado pela equipe de assistência devido uma condição materna ou fetal. O grupo controle foi composto pelas mulheres com parto a termo. Os partos prematuros foram categorizados, conforme recomendações da Organização Mundial da Saúde, em prematuro extremo, muito prematuros e pretermo moderado Uma quarta categoria de idade gestacional, contemplando apenas os prematuros tardios, também foi analisada. Variáveis relacionadas a características sociodemográficas, pôndero-estaturais e de estilo de vida maternos, características da assistência ao pré-natal e ao parto e sobre a presença de morbidade ou complicação durante a gravidez, parto ou puerpério foram avaliadas na análise de risco para parto prematuro terapêutico. Foi realizada uma análise bivariada para estimar o risco de parto prematuro terapêutico para cada e uma análise multivariada com regressão logística não condicional para obter os fatores independentemente associados ao desfecho. Resultados: O parto prematuro terapêutico foi responsável por 35,4% dos partos prematuros na amostra estudada. As síndromes hipertensivas, o descolamento prematuro de placenta e a diabetes foram as condições que mais frequentemente motivaram a resolução prematura da gravidez. A idade materna avançada, a hipertensão crônica, a obesidade e a gravidez múltipla foram as principais condições maternas relacionadas à ocorrência de parto prematuro terapêutico. Houve uma tentativa de tratamento da condição materna que motivou a resolução em mais de 50% dos casos e 74,5% das mulheres com parto entre 28 e 31 semanas receberam corticoterapia. A cesariana foi a via de parto mais frequente. A proporção de mortalidade neonatal, do Apgar do quinto minuto menor que sete e da admissão em unidade intensiva neonatal foi muito maior nos prematuros terapêuticos do que no termo, mesmo considerando os prematuros tardios. Conclusões: Os resultados do estudo corroboram com a crescente importância do parto prematuro terapêutico, devido sua prevalência e impacto nos resultados perinatais. A gravidez múltipla, idade materna avançada, a obesidade e a presença de morbidades pré-gestacionais são os fatores que requerem especial atenção nas estratégias de prevenção da prematuridade terapêutica
Abstract: Background: More than 15 million babies are born prematurely each year worldwide and its the leading cause of deaths in the neonatal period. Provider-initiated preterm birth (piPTB) plays an important role in this context because it is estimated that 20-40% of preterm births occur by indication of obstetric care providers. Thus, the reduction in piPTB rate acquires more importance to decrease the rate of prematurity and neonatal morbidity and mortality. Knowledge of the factors related to piPTB is a key factor to achieve this reduction. Objectives: To evaluate the occurrence of provider-initiated preterm birth and the associated factors in the Multicenter Study on Preterm Birth in Brazil (EMIP) population. Methods: Secondary analysis of EMIP, a Brazilian multicenter cross-sectional study plus a nested case-control. The study took place in 20 referral hospitals in 3 regions of Brazil from April 2011 to March 2012 and conducted surveillance of 33,740 deliveries in this period. The primary outcome to be evaluated is the occurrence of provider-initiated preterm birth, defined as birth that occurred before 37 weeks and was medically indicated due to maternal or foetal condition. The control group was composed of women with term delivery. Preterm birth was categorized into extremely premature, very premature and moderate preterm, according to the World Health Organization. Another category that includes only the late preterm was also evaluated. Maternal, socio-demographic, obstetrical, prenatal care, delivery and postnatal characteristics were assessed as factors associated with piPTB. A bivariate analysis to estimate the risk for piPTB and a multivariate analysis using unconditional logistic regression for the factors independently associated with piPTB was performed. Results: The therapeutic preterm labor accounted for 35.4% of premature births in the sample. Hypertensive disorders, placental abruption and diabetes were the main conditions related to pi-PTB indications. Advanced maternal age, chronic hypertension, obesity and multiple pregnancy were the main maternal conditions related to pi-PTB. There was an attempt to treat maternal condition that led to the resolution in over 50% of cases and 74.5% of women with birth between 28 and 31 weeks received corticosteroid therapy. Cesarean section was the most frequent mode of delivery. The proportion of neonatal mortality, Apgar score<7 at 5 minutes and NICU admission were much higher in provider-initiated preterm newborns than in term newborns, even considering the late preterms. Conclusions: The results of our study corroborate the increasing notability of provider-initiated preterm birth, due to its prevalence and impact on perinatal outcomes. Multiple pregnancies, advanced maternal age, obesity and the presence of pre-gestational morbidities are the main factors that require special attention in prematurity prevention strategies
Mestrado
Saúde Materna e Perinatal
Mestre em Ciências da Saúde

Introdução: A fisioterapia é uma especialidade relativamente recente dentro das Unidades de Terapia Intensiva Neonatais. Pelo sucesso obtido na prevenção e tratamento das complicações respiratórias, resultou no reconhecimento do fisioterapeuta como membro imprescindível da equipe multiprofissional. A fisioterapia neonatal pode causar impacto positivo no tratamento de neonatos prematuros de baixo peso, contribuindo para minimizar as complicações, principalmente respiratórias, além de reduzir o tempo de internação hospitalar e diminuir a morbidade neonatal. Pela necessidade de mais pesquisas nessa área, este estudo teve o objetivo de avaliar o impacto da implantação da assistência de fisioterapia respiratória sobre a morbidade de recém-nascidos prematuros de baixo peso. Método: Foram incluídos recém-nascidos internados na Unidade de Terapia Intensiva Neonatal do Hospital Universitário São Francisco, em Bragança Paulista, SP, com idade gestacional menor que 37 semanas, peso ao nascimento menor que 2500 g, diagnóstico de doença das membranas hialinas, submetidos à terapia de reposição de surfactante exógeno e permanência em ventilação mecânica por um período igual ou superior a sete dias. O estudo incluiu 101 neonatos, sendo 41 internados no período entre 2002 e 2004 (G1), em que não havia um serviço estruturado de fisioterapia hospitalar e 60 neonatos no período entre 2005 e 2007 (G2), em que já havia a estruturação do serviço, contando com fisioterapeuta xi exclusivo na Unidade. Os dois grupos foram comparados em relação a características maternas, neonatais e evolução durante a internação. Para a comparação dos grupos foram utilizados os testes estatísticos Mann-Whitney, Qui-quadrado e Teste exato de Fisher. A significância estatística foi estipulada em 5%. Resultados: Os dois grupos se mostraram homogêneos em relação às características maternas. Em relação às características neonatais, o G2 se mostrou mais grave por conter neonatos mais imaturos. Em relação à evolução, o G2 permaneceu maior tempo em oxigenioterapia (mediana de 11 dias), em ventilação não invasiva (mediana de 2 dias) e também em ventilação mecânica invasiva (mediana de 13 dias), porém utilizando picos de pressão inspiratória menores e frações inspiradas de oxigênio menores. No G2, 16 (26,6%) neonatos evoluíram com atelectasia contra 12 (29,3%) do G1. O G2 apresentou 17 (28,3%) neonatos com pneumonia contra 15 (36,5%) do G1. No G2, 14 (23,3%) neonatos evoluíram com displasia broncopulmonar contra 11 (26,8%) do G1. O G2 apresentou 3 (5%) neonatos com pneumotórax contra 3 (7,3%) do G1. O G2 apresentou 17 (28,3%) neonatos com sepse precoce e 48 (80,0%) com sepse tardia enquanto o G1 apresentou 8 (19,5%) e 27 (65,8%), respectivamente. O G2 apresentou maior tempo de internação hospitalar com mediana de 38 dias contra 30 dias de mediana do G1. A mortalidade do G1 foi de 3 (7,3 %) e do G2, de 8 (13,3 %). Conclusão: A fisioterapia respiratória pode auxiliar favoravelmente a evolução do recém-nascido prematuro de baixo peso, diminuindo as complicações respiratórias, obtendo assim impacto positivo na redução da morbidade respiratória neonatal
Introduction: Physiotherapy is a relatively new specialty in Intensive Care Units of Neonates. Considering the success of prevention and treatment of respiratory complications, as result of physiotherapy assistance, the physiotherapist is recognized as an indispensable member of multiprofessional team. Neonatal physiotherapy can cause positive impact on treatment of premature neonates of low birth weight, contributing to minimize the complications, especially of the respiratory type. Moreover it can reduce hospital stay and ameliorate the neonate morbidity. The need for research in this area leads to this study with the aim to assess the impact of the implantation of physiotherapy care on morbidity of premature newborn of low birth weight. Methods: Newborn in Intensive Care Unit of Neonates at Sao Francisco University Hospital in the city of Braganca Paulista (SP) were included in the study, with gestational age less than 37 weeks, birth weight lower than 2500 g, diagnosis of respiratory distress syndrome under replacement therapy of exogenous surfactant and permanence in mechanical ventilation ( 7 days). Subjects of the study included 101 neonates, 41 were admitted between 2002 and 2004 (group 1, G1), time that there was not a structured physiotherapy care in Intensive Care Units of Neonates and 60 neonates from 2005 to 2007 (G2), at this time there was the structured assistance with an exclusive physiotherapist at the Unit. Both groups were compared in relation to neonates maternal characteristics and xiii evolution during the hospital stay. Statistical analyses were applied for groups comparison, Mann-Whitney, chi square and Fisher exact test. Statistical significance was established at 5%. Results: The groups demonstrated homogeneity in relation to maternal characteristics. Neonate aspects had showed more severity for G2, this group had more immature neonates. In relation to evolution, G2 remained longer in oxygen therapy (median = 11 days), in non-invasive ventilation (median = 2 days) and also in invasive mechanical ventilation (median = 13 days), however, using lower inspiratory peak pressure and lower inspired oxygen fraction. In G2, 16 (26.6%) neonates evolved into atelectasis whereas 12 (29.3%) in G1. Seventeen (28.3%) neonates in G2 developed pneumonia and 15 (36.5%) in G1. In G2, 14 (23.3%) neonates evolved into bronchopulmonary dysplasia against 11 (26.8%) of G1. 17 (28.3%) neonates in G2 presented early sepsis and 48 (80.0%) late sepsis, while G1 presented 8 (19.5%) and 27 (65.8%), respectively. G2 had longer hospital stay with median of 38 days whereas G1 had median of 30 days. Mortality of G1 was of 3 (7.3%) neonates and 8 (13.3%) of G2. Conclusion: Respiratory Physiotherapy can help favorably the evolution of premature newborn of low birth weight, diminishing respiratory complications, impacting therefore positively to reducing neonate respiratory morbidity

INTRODUÇÃO: O baixo peso ao nascer representa fator de risco importante para a morbidade e mortalidade neonatal e infantil, sendo acompanhado por prematuridade, retardo de crescimento intra-uterino, ou ambos os fatores. OBJETIVO: Estudar as características maternas, perinatais, ambientais, econômicas, evolução ponderoestatural e alimentação das crianças nascidas com baixo peso e sua interação no aumento da morbidade durante o primeiro ano de vida. MÉTODOS: Estudo de coorte retrospectivo realizado na cidade de Sobral, Ceará, no período de três anos (2005 a 2007) onde foram incluídas 261 crianças nascidas com baixo peso (BP) e acompanhadas pelo Programa de Saúde da Família. Foi utilizado a Base de Dados do Sistema de Informações de Nascidos Vivos e revisão de prontuários hospitalares e ambulatoriais destas crianças para coleta de dados, quantificação e causa das consultas e internações. Para análise das variáveis foram realizadas distribuições de freqüência, Odds Ratio (OR), respectivos intervalos de confiança (95%) e significância estatística das associações. A análise final de associação utilizou modelo de regressão multivariado para avaliar os fatores de risco relacionados com o aumento da morbidade. RESULTADOS: Entre as 261 crianças estudadas, a média da idade materna foi de 24 anos, sendo que 29,12% das mães eram adolescentes. Cerca de 41,76 % das mães eram solteiras e 31,42% casadas ou com união estável, e 24,14% eram sem escolaridade. Quanto às características perinatais, 52,11% das crianças nasceram de parto vaginal, 52,49% pré-termos; 55,56% eram do sexo feminino, 98,08% das crianças obtiveram Apgar de 5 minutos maior que 6. O peso médio de nascimento foi de 2140 g, sendo que 72,03% das crianças nasceram com peso entre 2000 e 2500 g. Houve incremento do escore-z de peso até os quatro meses de idade cronológica para crianças nascidas a termo e idade gestacional corrigida para os pré-termo em cerca de 87% das crianças e 45% do escore-z do comprimento. O índice de aleitamento materno exclusivo foi de 26,05% e 8,43% até os 4 e 6 meses de idade respectivamente. Observou-se que 13,97% das crianças residiam em casa de taipa, 36,49% dos domicílios utilizavam fogão a lenha e 36,11% viviam com renda familiar inferior a um salário mínimo. Quanto a morbidade, as 261 crianças nascidas com baixo peso realizaram 1103 consultas por motivo de doença no Programa de Saúde de Família, tendo como causa principal infecções respiratórias agudas. Ocorreram 469 consultas ocorreram em emergência pediátrica e 156 internações hospitalares, principalmente no período neonatal. Foram identificados como fatores de risco para maior morbidade: a) Interrupção do aleitamento materno exclusivo antes dos quatro meses o qual esteve associado a presença de consulta em emergência (OR 3,07; p<0,001); b) Idade gestacional e peso de nascimento baixos, com maior probabilidade de internação no período neonatal (OR 6,26; p<0,001); c) Prematuridade e a ausência de recuperação de peso até os 4 meses estiveram associados a internação por pneumonia, diarréia aguda e outros motivos (OR 5,15 e 0,65; p = 0,036 e 0,013, respectivamente). As demais variáveis não tiveram relação com a morbidade estudada. CONCLUSÃO: A prematuridade, a interrupção do aleitamento materno exclusivo antes dos quatro meses e a ausência do incremento de peso estiveram associadas a maior morbidade nas crianças de baixo peso ao nascer. Nesta população atendida pelo PSF, as características maternas, ambientais e econômicas não estiveram associadas à maior morbidade
BACKGROUND: Low birth weight represents an important risk factor for neonatal and infant morbidity and mortality, accompanied by prematurity, intrauterine growth restriction, or both. OBJECTIVE: To study maternal, perinatal, environmental, economic characteristics, growth and feeding of children with low birth weight and their interaction in the increased morbidity during the first year of life. METHODS: A retrospective cohort study conducted in the city of Sobral, Ceará, in the period of three years (2005-2007) which included 261 children with low birth weight (LBW) and followed by the Family Health Program. We used the database of the Sistema de Informação de Nascidos Vivos (SINASC) and review data collection of hospital and ambulatory records of these children, quantification and causes of emergency room visits and hospitalizations. For analysis of the variables, were used frequency distributions, odds ratio (OR), confidence intervals (95%) and statistical significance of associations. The final analysis of association used logistic regression analysis to assess the risk factors associated with increased morbidity. RESULTS: Among 261 children studied, the average maternal age was 24 years, and 29.12% of mothers were teenagers. Approximately 41.76% were single mothers and 31.42% were married or with a stable union, and 24.14% were uneducated. Regarding perinatal characteristics, 52.11% were born vaginally, 52.49% were preterm, 55.56% were female and 98.08% of the children had Apgar 5 minutes greater than 6. The average birth weight was 2140 g, and 72.03% of children born weighing between 2000 and 2500 g. There was catch up in weight to four months of chronological age for children born at term and corrected gestational age for preterm at around 87% and 45% in height. The rate of exclusive breastfeeding was 26.05% and 8.43% to 4 and 6 months of age respectively. It was observed that 13.97% of children lived in wattle and daub house, 36.49% of households used wood stoves, and 36.11% lived with less than one minimum wage. As for morbidity, the 261 children born with low birth weight were 1103 visits due to illness in the Family Health Program, with the main cause was acute respiratory infections. There were 469 emergency visits and 156 pediatric emergency hospital admissions, especially in the neonatal period. Were identified as risk factors for increased morbidity: a) interruption of exclusive breastfeeding before 4 months which was associated with the presence of emergency consultation (OR 3.07, p <0.001), b) low gestational age and birth weight, with a greater likelihood of hospitalization in the neonatal period (OR 6.26, p <0.001), c) Prematurity and the no catch up in weight at to 4 months of age were associated with hospitalization for pneumonia, diarrhea and other reasons (OR 5, 15 and 0.65, p = 0.036 and 0.013, respectively). The other variables were not associated with morbidity study. CONCLUSION: Prematurity, interruption of exclusive breastfeeding before four months and no catch up growth were associated with greater morbidity in children with low birthweight. In the population served by the PSF, maternal characteristics, environmental and economic were not associated with increased morbidity

Uvod: Infertilitet se definiše kao bezuspešna koncepcija nakon jedne godine seksualnih odnosa bez upotrebe kontracepcije u fertilnoj fazi menstrualnog ciklusa. Metode asistirane reprodukcije predstavljaju efektivan način lečenja infertiliteta. Ispitivanje i identifikacija kratkoročnih i dugoročnih efekata arteficijalnih reproduktivnih tehnologija je veoma izazovan zadatak. Prvenstveni razlog tome je velika heterogenost u načinu sakupljanja, obrade, klasifikacije i tumačenja, sada već, obilja informacija koje su prikupljene u različitim istraživanjima. Individualni pristup lečenju neplodnosti, brz napredak i stalne promene u metodologiji arteficijalnih reproduktivnih tehnologija, uz ranije navedene poteškoće u vezi sa prikupljanjem i analizom podataka, značajno otežavaju precizno sagledavanje svih mogućih rizika i posledica arteficijanog začeća. Uprkos brojnim istraživanjima, naučnim publikacijama i akumuliranim dokazima, ostale su mnoge dileme u vezi odgovora na pitanja - da li su arteficijalno začete trudnoće u većoj meri praćene rizicima za neadekvatan razvoj ploda, lošijim perinatalnim ishodom i kakve su dugoročne posledice po decu, kao i da li su ovi rizici podjednako zastupljeni u jednoplodnim i višeplodnim trudnoćama.Cilj rada: Ciljevi rada su bili da se utvrdi struktura morbiditeta kod prevremeno rođene dece začete vantelesnom oplodnjom (iz jednoplodnih i višeplodnih trudnoća) u prve dve godine života, te da se identifikuju perinatalni faktori koji su povezani sa pojavom akutnih i hroničnih komplikacija i oboljenja kod prevremeno rođene dece začete vantelesnom oplodnjom. Takođe, cilj rada je bio da se utvrde karakteristike psihomotornog razvoja kod prevremeno rođene dece začete vantelesnom oplodnjom na kraju dvanestog, osamnaestog i dvadesetčetvrtog meseca života, kao i da se identifikuju specifični faktori rizika za nepovoljan telesni, neurološki i psihološki ishod lečenja kod prevremeno rođene dece začete vantelesnom oplodnjom.Materijal i metode: U studiju su uključena prevremeno rođena deca koja su bila hospitalizovana u Službi za neonatologiju i intenzivnu i poluintenzivnu negu i terapiju, i koja su nakon toga, tokom prve dve godine života redovno praćena u neonatološkoj ambulanti Instituta za zdravstvenu zaštitu dece i omladine Vojvodine u Novom Sadu. Retrospektivnim delom studije su obuhvaćena deca koja su lečena u Službi i praćena u neonatološkoj ambulanti, a koja su rođena počev od 01. 01. 2011. do 31.12.2012. godine i praćena do navršena puna 24 meseca života. Podaci o pacijentima koji su uključeni u retrospektivni deo istraživanja prikupljani su pregledom medicinske dokumentacije. U prospektivni deo studije su uključena deca koja su lečena u Službi i koja su praćena u neonatološkoj ambulanti, a koja su rođena između 01.01. 2013.godine i 31.12.2014. godine i potom praćena do navršenih 24 meseca života. Iz navedene kohorte, formirane se dve grupe: Ispitivana grupa (Grupa 1) je obuhavatila svu prevremeno rođenu decu začetu vantelesnom oplodnjom koja su bila hospitalizovana i praćena na Institutu u navedenom periodu. Kontrolna grupa (Grupa 2) obuhvatila je prevremeno rođenu decu začetu prirodnim putem. Deca iz kontrolne grupe izabrana su iz kohorte tako da njihov broj bude jednak broju dece iz ispitivane grupe. Ispitanici iz ove grupe su ujednačeni (''mečovani'') sa decom iz ispitivane grupe prema gestacijskoj starosti i datumu rođenja. Gestacijska starost ispitanika iz kontrolne grupe se ne razlikuje za više od ± 4 dana u odnosu na decu iz ispitivane grupe. Datum rođenja ispitanika koji su uključeni u kontrolnu grupu se ne razlikuje za više od ± 3 meseca u odnosu na decu iz ispitivane grupe.U momentu uključivanja u studiju uzimani su sledeći anamezni podaci:Podaci u vezi sa majkom, trudnoći i porođaju: starost majke u momentu koncepcije, broj prethodnih pokušaja asistirane koncepcije, stručna sprema, mesto stanovanja, hronične bolesti dijagnostikovane pre trudnoće, akutne i hronične bolesti dijagnostikovane tokom trudoće (hipertenzija, pre-eklampsija, eklampsija, oštećenje jetre), prevremena ruptura plodovih ovojaka, primena lekova tokom trudnoće, jednoplodna ili višeplodna trudnoća. Podaci o poremećajima posteljice i ovojaka: ablacija, placenta previja, horioamnionitis. Podaci u vezi sa detetom: intrauterina infekcija, intrauterina restrikcija rasta, način porođaja, Apgar skor. Antropometrijski parametri (telesna masa, telesna dužina, obim glave) na rođenju i tokom perioda ambulantnog praćenja deteta. Dužina inicijalne hospitalizacije deteta. Dužina invazivne i/ili neinvazivne respiratorne potpore i oksigenoterapije. Dijagnoze na otpustu iz bolnice: prisustvo teških posledica prematuriteta, što podrazumeva: intrakranijalnu hemoragiju 3. i 4. stepena (definisanu u međunarodnoj klasifikaciji bolesti – deseta revizija (MKB10) pod šifrom P52.2), cističnu periventrikularnu leukomalaciju, retinopatiju prematuriteta, bronhopulmonalnu displaziju, nekrotizirajući enterokolitis, sepsu i/ili meningitis (mikrobiološki ili klinički dijagnostikovanu). Prisustvo urođenih anomalija ili genetskih sindroma i bolesti (definisanih u MKB10 pod šiframa Q00 do Q99), kao i prisustvo urođenih bolesti metabolizma (definisanih u MKB10 pod šiframa E00 do E90).U retrospektivnom delu studije, pregledani su specijalistički izveštaji iz neonatološke ambulante pri posetama deteta u uzrastu deteta od 12, 18 i 24 meseca, i beleženi su sledeći podaci: sve prethodno postavljene dijagnoze koje su navedene na specijalističkim izveštajima iz neonatološke ambulante, antropometrijski prametri u momentu pregleda (telesna dužina, telesna masa i obim glave), neurološki nalaz (tonus, trofika, kožni i tetivni refleksi, prisustvo lateralizacije u neurološkom nalazu), nalaz oftalmologa (uredan nalaz/pataloški nalaz), procena fine i grube motorike, govora, kognitivne funkcije i socijalnog kontakta i zbirna procena psihomotornog razvoja. U prospektivnom delu studije, pri kontrolnim pregledima u neonatološkoj ambulanti, u uzrastu deteta od 12, 18 i 24 meseca, određivano je i beleženo sledeće: ranije postavljene dijagnoze koje su navedene u medicinskoj dokumentaciji, antropometrijski prametri u momentu pregleda (telesna dužina, telesna masa i obim glave), neurološki nalaz (tonus, trofika, kožni i tetivni refleksi, prisustvo lateralizacije u neurološkom nalazu), nalaz oftalmologa (uredan nalaz/pataloški nalaz), procena fine i grube motorike, govora, kognitivne funkcije i socijalnog kontakta i zbirna procena psihomotornog razvoja.Rezultati: Prosečna vednost TM ispitanika iz Grupe 1, u uzrastu od 12 meseci, bila je statistički značajno manja u odnosu na ispitanike iz Grupe 2 (Studentov t test). Prosečne vednosti TD ispitanika iz obe grupe, u uzrastu od 12 meseci, nisu se statistički značajno razlikovale (Studentov t test). Prosečne vednosti OGL ispitanika iz obe grupe, u uzrastu od 12 meseci, nisu se statistički značajno razlikovale (Studentov t test). Udeo ispitanika sa patološkim oftalmološkim nalazom nije se statistički značajno razlikovao između Grupe 1 i Grupe 2 (Fišerov test tačne verovatnoće). Udeo ispitanika sa patološkim neurološkim nalazom nije se statistički značajno razlikovao između Grupe 1 i Grupe 2 (Hi kvadrat test). Prosečne vrednosti globalnog koeficijenta razvoja (RQ), kao i prosečne vrednosti skora za pojedine elemente za procenu razvoja (motorika, koordinacija, govor i društvenost) po Brunet -Lézine skali, nisu se statistički značajno razlikovale između grupa (Studentov t test). U Grupi 1 bilo je 92 (59,740%) deteta čiji je nekorigovani RQ bio ispod 90, dok je u Grupi 2 bilo 61 (39,610%) dete čiji je nekorigovani RQ bio ispod 90. Ova razlika u broju dece sa RQ koji je ispod proseka za kalendarski uzrast je statistički značajna (Hi kvadrat test, p=0,0004). Relativni rizik za ispodprosečno postignuće na testu za procenu psihomotornog razvoja (RQ<90), za decu iz Grupe 1 bio je viši, u odnosu na decu iz Grupe 2 (RR = 1,495; 95% CI 1,181 – 1,892). U Grupi 1, bilo je 87 (56,494%) dece koja su postigla ispodprosečne korigovane vrednosti skora na testu za procenu psihomotornog razvoja (korigovani RQ<90). U Grupi 2 bilo je 69 (44,805%) dece koja su postigla ispodprosečne korigovane vrednosti skora na testu za procenu psihomotornog razvoja (korigovani RQ<90). Ova razlika je statistički značajna (Hi kvadrat test, p =0,040). Relativni rizik za ispodprosečno postignuće na testu za procenu psihomotornog razvoja (korigovani RQ<90), za decu iz Grupe 1 bio je viši, u odnosu na decu iz Grupe 2 (RR = 1,261; 95%CI 1,008 – 1,577). U kategoriji dece, koja su i pored korekcije u odnosu na GS imala ispodprosečno postignuće na testu za procenu psihomotornog razvoja, u Grupi 1 čak 81/87 (93,310%) dece je imalo vrednost korigovanog RQ ≥ 85, a u Grupi 2 ovu vrednost korigovanog RQ imalo je 60/69 (86,956%) dece.Prosečne vednosti TM ispitanika iz obe grupe, u uzrastu od 18 meseci, nisu se statistički značajno razlikovale (Studentov t test). Prosečne vednosti TD ispitanika iz obe grupe, u uzrastu od 18 meseci, nisu se statistički načajno razlikovale (Studentov t test). Prosečne vednosti OGL ispitanika iz obe grupe, u uzrastu od 18 meseci, nisu se statistički značajno razlikovale (Studentov t test). Udeo ispitanika sa patološkim oftalmološkim nalazom nije se statistički značajno razlikovao između Grupe 1 i Grupe 2 (Hi kvadrat test). Udeo ispitanika sa patološkim neurološkim nalazom nije se statistički značajno razlikovao između Grupe 1 i Grupe 2 (Hi kvadrat test). Prosečne vrednosti RQ, kao i prosečne vrednosti skora za pojedine elemente za procenu razvoja (motorika, koordinacija, govor i društvenost) po Brunet -Lézine skali su se statistički značajno razlikovale između grupa u uzrastu od 18 meseci (Studentov t test). U Grupi 1 bilo je 57 (37,013%) dece čiji je nekorigovani RQ bio ispod 90, dok je u Grupi 2 bilo 31 (20,130%) dete čiji je nekorigovani RQ bio ispod 90. Udeo dece sa RQ koji je ispod proseka za kalendarski uzrast je statistički značajno različit između grupa (Hi kvadrat test, p = 0,010). Relativni rizik za ispodprosečno postignuće na testu za procenu psihomotornog razvoja (nekorigovani RQ<90), za decu iz Grupe 1 bio je viši, u odnosu na decu iz Grupe 2 (RR = 1,288; 95%CI 1,181 – 2,730). Statistički značajna razlika postojala je i kada je upoređen broj dece sa vrednostima korigovanog RQ ispod 90 u Grupi 1 i Grupi 2 (36 naspram 19 po redosledu navođenja; Hi kvardat test, p = 0,011). Relativni rizik za ispodprosečno postignuće na testu za procenu psihomotornog razvoja (korigovani RQ<90), za decu iz Grupe 1 bio je viši, u odnosu na decu iz Grupe 2 (RR = 1,895; 95%CI 1,139 – 3,152).Prosečne vednosti TM ispitanika iz obe grupe, u uzrastu od 24 meseca, nisu se statistički značajno razlikovale (Studentov t test). Prosečne vednosti TD ispitanika iz obe grupe, u uzrastu od 24 meseca, nisu se statistički značajno razlikovale (Studentov t test). Prosečne vednosti OGL ispitanika iz obe grupe, u uzrastu od 24 meseca, nisu se statistički značajno razlikovale (Studentov t test). Udeo ispitanika sa patološkim oftalmološkim nalazom nije se statistički značajno razlikovao između Grupe 1 i Grupe 2 (Hi kvadrat test). Udeo ispitanika sa patološkim neurološkim nalazom nije se statistički značajno razlikovao između Grupe 1 i Grupe 2 (Hi kvadrat test). Prosečne vrednosti RQ, kao i prosečne vrednosti skora za pojedine elemente za procenu razvoja (motorika, koordinacija, govor i društvenost) po Brunet -Lézine skali, nisu se statistički značajno razlikovale između grupa, u uzrastu od 24 meseca (Studentov t test). U Grupi 1 bilo je 21 dete (13,636%) čiji je nekorigovani RQ bio ispod 90, dok je u Grupi 2 bilo 17 (11,049%) dece čiji je nekorigovani RQ bio ispod 90. Razlika u broju dece sa RQ koji je ispod proseka za kalendarski uzrast nije statistički značajna (Hi kvadrat test, p= 0,488). Statistički značajna razlika nije postojala ni kada je upoređen broj dece sa vrednostima korigovanog RQ ispod 90 u Grupi 1 i Grupi 2 (12 naspram 9 po redosledu navođenja; Hi kvardat test, p = 0,497).Logističkom regresionom analizom pokazano je da su veštačko začeće, višeplodnost trudnoće i IUGR nezavisni faktori rizika za manju TM u kalendarskom uzrastu od 12 meseci. Logističkom regresionom analizom dobijena je statistički značajna korelacija između vrednosti RQ u uzrastu od 18 meseci i sledećih nezavisnih varijabli: arteficijalno začeta trudnoća i višeplodna trudnoća. Isptanici iz Grupe 1 i Grupe 2 nisu se statistički značajno razlikovali ni po jednom od posmatranih pokazatelja telesnog i psihomotornog razvoja u uzrastu od 24 meseca.Struktura morbiditeta kod dece, tokom dvogodišnjeg perioda praćenja, nije se značajno razlikovala između grupa. Jedina razlika između grupa, konstatovana je u uzrastu od 12 i 18 meseci, bila je u učestalosti akutnih respiratornih infekcija, čija je pojava, pak, bila direktno povezana sa višeplodnim trudnoćama, odnosno brojem siblinga u domaćinstvu.Zaključak: Prosečna starost majki dece koja su začeta IVF-om je veća od prosečne starosti majki dece koja su spontano začeta. Struktura morbiditeta majki dece koja su začeta IVF-om i majki dece koja su začeta spontanom koncepcijom je ista, ali je stopa morbiditeta veća kod majki dece koja su začeta IVF-om. Višeplodne trudnoće su veoma zastupljene kod začeća IVF-om. Trudnoće začete IVF-om se dominantno i skoro ekskluzivno okončavaju carskim rezom. Prevremena ruptura ovojaka ploda je česta komplikacija trudnoća koje su začete IVF-om. Stopa morbiditeta prevremeno rođene dece začete vantelesnom oplodnjom nije veća u odnosu na prevremeno rođenu decu začetu prirodnim putem. U strukturi morbiditeta kod dece koja su začeta vantelesnom opodnjom, zastupljena su ista oboljenja i komplikacije kao kod prevremeno rođene dece začete prirodnim putem. Incidencija pojedinih oboljenja je ista, sa izuzetkom bronhopulmonalne displazije koja se javlja češče kod dece začete vantelesnom oplodnjom i retinopatije prematuriteta koja se javlja češče kod dece začete prirodnim putem. Porođajna telesna masa, intrauterina restrikcija rasta, starost majke, stručna sprema majke, prethodna hronična oboljenja majke, bolesti majke dijagnostikovane tokom trudnoće, jednoplodna i višeplodna trudnoća, način porođaja i PROM su potencijalni faktori rizika za lošiji postnatalni ishod kod dece iz arteficijalno začetih trudnoća. U uzrastu od 12 meseci, prevremeno rođena deca začeta tehnikama in vitro fetrilizacije, sem po dostignutoj telesnoj masi, ne razlikuju se značajno po drugim telesnim karakteristikama, od prevremeno rođene dece koja su začeta prirodnim putem. Faktori rizika za manju telesnu masu kod prevremeno rođene dece, u uzrastu od 12 meseci su: arteficijalno začeće, višeplodne trudnoće i intrauterina restrikcija rasta. U uzrastu od 12 meseci, prevremeno rođena deca začeta in vitro fertilizacijom, imaju blago lošije (ali ne i značajno niže) postignuće na testovima za procenu psihomotornog razvoja, odnosno imaju viši rizik da postignu ispodprosečne vrednosti skora na testu za procenu psihomotornog razvoja. U uzrastu od 18 meseci, nema razlike u pokazateljima telesnog razvoja između prevremeno rođene dece koja su arteficijalno začeta i dece koja su rođena iz spontano začetih trudnoća. U uzrastu od 18 meseci, prevremeno rođena deca iz arteficijalno začetih trudnoća imaju niže postignuće na testovima za procenu psihomotornog razvoja u odnosu na prevremeno rođenu decu iz spontano začetih trudnoća. Faktori rizika koji su povezani sa lošijim postignućem na testu za procenu psihomotornog razvoja kod prevremeno rođene dece su arteficijalno začeće trudnoće i višeplodnost trudnoće. U uzrastu od 24 meseca nema razlike u telesnim parametrima između prevremeno rođene dece koja su arteficijalno začeta i prevremeno rođene dece koja su začeta prirodnim putem. U uzrastu od 24 meseca nema razlike u postignuću na testu za procenu psihomotornog razvoja kod prevremeno rođene dece su arteficijalno začeće trudnoće i višeplodnost trudnoće. U uzrastu od 24 meseca, prevremeno rođena deca, i iz arteficijalno, i iz spontano začetih trudnoća, na testu za procenu psihomotornog razvoja postižu rezultate koji su u skladu sa njihovim kalendarskim uzrastom.
Introduction: Infertility is defined as an unsuccessful conception after one year of sexual intercourse without the use of contraception in the fertilizing phase of the menstrual cycle. Assisted reproduction methods represent an effective way of treating infertility. Examination and identification of short-term and long-term effects of artificial reproductive technologies is a very challenging task. The primary reason for this is the great heterogeneity in the way of collecting, processing, classifying and interpreting, now, the abundance of information that has been gathered in various studies. Individual approach to the treatment of infertility, rapid progress and constant changes in the methodology of the artificial reproductive technologies, in addition to the aforementioned difficulties associated with the collection and analysis of data, significantly hamper accurate assessment of all possible risks and consequences artificial conception. Despite numerous studies, scientific publications and the accumulated evidence, many doubts about the question whether artificially conceived pregnancies are accompanied by the higher risks or inadequate fetal development, poor perinatal and long-term outcomes still remained.The Aim: The objectives of this work were to determine the structure of morbidity in prematurely born children conceived by artificial reproductive technologies (from single and multiple pregnancies) in the first two years of life, and to identify perinatal factors that are associated with the occurrence of acute and chronic complications and diseases in prematurely born children from this pregnancies. In addition, the aim of the study was to determine the characteristics of psychomotor development in prematurely born children conceived by artificial reproductive technologies at the end of the twelfth, eighteenth and twenty-fourth month of life, as well as to identify specific risk factors for the unfavorable physical, neurological and psychological outcome of those children.Materials and Methods: The study included premature born newborns who were hospitalized in the Department for neonatology and intensive and semi-intensive care unit, and are thereafter, during the first two years of life. The retrospective part of the study included children who were hospitalized at the Institute, and who were born from January 1st 2011. to December 31st 2012. and were followed up to 2 years of life. Data on patients included in the retrospective part of the survey were collected through a review of medical records. The prospective part of the study included children who were treated and followed up at the Institute, and who were born between January 1st 2013 and December 31st 2014. and then followed up to 2 years of life. From this cohort two groups were formed: The tested group (Group 1) included all preterm infants who were conceived by ART. The control group (Group 2) included naturally conceived prematurely born children. The children in the control group were selected from the cohort so that their number was equal to the number of children in the study group. The gestational age of the examinees from the control group does not differ for more than ± 4 days from the children from the study group. The date of birth of subjects included in the control group does not differ for more than ± 3 months from the children in the study group.At the moment of inclusion in the study, the following individual data were taken:Maternal data, pregnancy and childbirth: the age of the mother at the moment of conception, the number of previous attempts at assisted conception, professional care, place of residence, chronic diseases diagnosed before pregnancy, acute and chronic diseases diagnosed during pregnancy (hypertension, pre-eclampsia, eclampsia, liver damage), premature rupture of the fetuses, the use of medication during pregnancy, single or multiple pregnancy. Data on placental disorders and abnormalities: ablation, placenta overdose, horioamnionitis. Child-related data: intrauterine infection, intrauterine growth restriction, delivery method, Apgar score. Anthropometric parameters (body weight, body length, head circumference) at birth and during the period of outpatient monitoring of the child. Length of initial hospitalization of the child. Length of invasive and / or non-invasive respiratory support and oxygen therapy. Diagnosis on discharge from the hospital: the presence of severe consequences of prematurity, which implies intracranial hemorrhage of 3rd and 4th degree (defined in International Classification of Disease - Tenth Revision (MKB10) under code P52.2), cystic periventricular leukomalacia, retinopathy of prematurity, bronchopulmonary dysplasia , necrotizing enterocolitis, sepsis and / or meningitis (microbiologically or clinically diagnosed). Presence of congenital anomalies or genetic syndromes and diseases (defined in MKB10 under codes Q00 to Q99), as well as the presence of congenital metabolic diseases (defined in MKB10 under codes E00 to E90).In the retrospective part of the study, specialist reports from a neonatological clinic were examined for child visits at the age of 12, 18 and 24 months, and the following data were ecorded: all pre-diagnosis reported on specialist reports from a neonatological clinic, anthropometric arms at the moment examination (body length, body weight and head circumference), neurological findings (tone, trophic, skin and tendon reflexes, presence of lateralization in neurological findings), ophthalmologist findings (neat / patial findings), assessment of fine and coarse motoring, speech, cognitive functions and social contact and a collective assessment of psychomotor development. In the prospective part of the study, during control examinations in a neonatological clinic, at the age of 12, 18 and 24 months, the following were determined and recorded: previously set out in the current medical documentation, anthropometric parameters at the moment of examination (body length, body weight and the volume of the head), neurological findings (tone, trophic, skin and tendon reflexes, presence of lateralization in neurological findings), ophthalmologist findings, assessment of fine and grose motor functions, speech, cognitive functions, social contact and psychomotor development.Results: The average BW of subjects in Group 1 at the age of 12 months, was statistically significantly lower in relation to respondents from Group 2 (Student's T test). The average length of subjects from both groups at the age of 12 months did not statistically differ (Student's T test). The average head circumference between children from both groups, at the age of 12 months, did not statistically differ (Student's T test). The proportion of subjects with pathological ophthalmological findings did not statistically significantly differ between Group 1 and Group 2 (Fischer's exact probability test). The proportion of subjects with pathological neurological findings did not statistically significantly differ between Group 1 and Group 2 (Hi square test). The average values of the global development coefficient (RQ), as well as the average score values for individual elements of development evaluation test - Brunet-Lézine scale (motor function, coordination, speech and sociability) did not differ significantly between groups (Student t test). In Group 1 there were 92 (59.740%) of children whose uncorrected RQ was under 90, while in Group 2 there were 61 (39.610%) children whose uncorrected RQ was below 90. This difference in the number of children with RQ below the average for calendar age is statistically significant (Hi square test, p = 0.0004). The relative risk of under-achievement in the psychomotor evaluation test (RQ <90) for children from Group 1 was higher than in children from Group 2 (RR = 1.495; 95% CI 1.181 - 1.922). In Group 1, there were 87 (56.494%) children who achieved sub-optimal corrected score values for the assessment of psychomotor development (corrected RQ <90). In Group 2, there were 69 (44.805%) children who achieved sub-optimal corrected score values for the assessment of psychomotor development (corrected RQ <90). This difference is statistically significant (Hi square test, p = 0.040). The relative risk for the suboptimal achievement in the psychomotor evaluation test (corrected RQ <90) for children from Group 1 was higher than in Group 2 (RR = 1.261; 95% CI 1.008 - 1.577). In Group 1, as many as 81/87 (93.310%) of children had a corrected RQ value of ≥ 85, while in Group 2 this value of the corrected RQ there were 60/69 (86.956%) children.At the age of 18 months, the average BW of subjects from both groups did not differ significantly (Student's T test). The average length of subjects from both groups, at the age of 18 months, did not statistically differ (Student's T test). The average head circumference of children from both groups, at the age of 18 months, did not statistically differ (Student's T test). The proportion of subjects with pathological ophthalmological findings did not statistically significantly differ between Group 1 and Group 2 (Hi square test). The proportion of subjects with pathological neurological findings did not statistically differ between Group 1 and Group 2 (Hi square test). The average RQ values, as well as the average scores for individual elements of psychomotor development (motor function, coordination, speech and sociability) according to the Brunet-Lézine scale, have been statistically significantly different between groups, at the age of 18 months (Student's T test). In Group 1 there were 57 (37.013%) children whose uncorrected RQ was below 90, while in Group 2 there were 31 (20,130%) children whose uncorrected RQ was below 90. The share of children with RQ below the average value for the calendar age is statistically significantly different between groups (Hi square test, p = 0.010). The relative risk for the suboptimal achievement in the Psychomotor Development Assessment (uncorrected RQ <90) for Group 1 children was higher than in Group 2 (RR = 1.288; 95% CI 1.181 - 2.730). A statistically significant difference between Group 1 and Group 2 existed when the number of children with corrected RQ below 90 was compared (36 naspram 19 respectively, Hi quadrate test, p = 0.011). The relative risk for the suboptimal achievement on the Psychomotor Evaluation Test (corrected RQ <90) for the children from Group 1 was higher when compared to children in Group 2 (RR = 1.895; 95% CI 1.139 – 3.152).At the age of 24 months the average BW, body length and head circumference of subjects in both groups were not significantly different (Student's T test). The proportion of subjects with pathological ophthalmological findings did not statistically significantly differ between Group 1 and Group 2 (Hi square test). The proportion of subjects with pathological neurological findings did not statistically significantly differ between Group 1 and Group 2 (Hi square test). The average RQ values, as well as the average score values for individual elements for development evaluation (motor function, coordination, speech and sociability) according Brunet-Lézine scale, did not significantly differ between groups at the age of 24 months (Student's T test). In Group 1, there were 21 children (13.636%) whose uncorrected RQ was under 90, while in Group 2 there were 17 (11.049%) of children whose uncorrected RQ was below 90. The difference in the number of children with RQ below the average for the calendar age was not statistically significant (Hi square test, p = 0.488). A statistically significant difference did not exist even when the number of children with values of the corrected RQ below 90 in Group 1 and Group 2 (12 naspram 9 respectively, Hi quadrate test, p = 0.497) was compared.Logistic regression analysis has shown that artificial conception, multiple pregnancy and IUGR are independent risk factors for lesser BW in a calendar age of 12 months. By logistic regression analysis, a statistically significant correlation between RQ values at 18 months of age and the following independent variables was obtained: artificially started pregnancy and multiple pregnancy. Group 1 and Group 2 patients did not significantly differ by any of the indicators of physical and psychomotor development at the age of 24 months.The structure of morbidity in children, during the two-year follow-up period, did not differ significantly between groups. The only difference between the groups was found in the rates of acute respiratory infections at the age of 12 and 18 months (rate of infections was higher in Group 1), whose occurrence, however, was directly related to multiple pregnancies, or the number of sibling in the household.Conclusion: The average age of mothers of children conceived by the IVF is higher than the average age of mothers of children who were conceived spontaneously. The structure of the morbidity of mothers of children who were artificially conceived and mothers of children born after spontaneous conception is the same, but the morbidity rate is higher in the mothers of children who were conceived by IVF. Pregnancies concieved by IVF almost exclusively ended by cesarean section. Premature rupture of the membranes is a common complication of IVF pregnancies. The rate of morbidity of prematurely born children conceived by ART is not higher than that of prematurely born children conceived naturally. The structure of morbidity in children from ART pregnancies was the same as in naturally conceived prematurely born children. The incidence of specific illnesses is the same, with the exception of bronchopulmonary dysplasia that occurs more frequently in children born from ART pregnancies, and retinopathy of prematurity that occurs more frequently in spontaneously conceived children. Maternal birth weight, intrauterine growth restriction, mother's age, maternal care, previous mother's chronic illness, mother's disease diagnosed during pregnancy, single and multiple pregnancies and PROM are potential risk factors for worse postnatal outcome in children from artificially initiated pregnancies. Risk factors for lower body weight in premature babies, at the age of 12 months, are: artificial conception, multiple pregnancy and intrauterine growth restriction. At the age of 12 months, prematurely born children from IVF pregnancies, have slightly worse (but not significantly lower) psychomotor achievements. At the age of 18 months, there is no difference in the indicators of physical development between prematurely born children who are artificially conceived and children born from spontaneous pregnancies. At the age of 18 months, prematurely born children from ART pregnancies have lower achievement on tests for assessing psychomotor development compared to prematurely born children from spontaneously initiated pregnancies. Risk factors associated with a poor performance on the psychomotor development assessment tests, in preterm infants, are an artificial conception of pregnancy and a multi fertile pregnancy. At the age of 24 months, there is no difference in the physical parameters between prematurely born children from ART and naturally conceived pregnancies. At the age of 24 months, there is no difference in the achievement on the test for the assessment of psychomotor development between children from ART and spontaneous pregnancies. At the age of 24 months, on the psychomotor development assessment, prematurely born children achieve the results consistent with their calendar age.

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Objetivos: determinar a incidência de displasia broncopulmonar durante o período de um ano (março de 2009 a fevereiro de 2010) e analisar os fatores de risco neonatais associados ao desenvolvimento da doença em serviços públicos de referência para alto risco neonatal em Maceió, o Hospital Universitário Prof. Alberto Antunes e a Maternidade Escola Santa Mônica. Métodos: foram registrados dados de todos os prematuros de muito baixo peso admitidos nas duas instituições durante um ano. O diagnóstico de displasia broncopulmonar foi estabelecido naqueles prematuros com necessidade de oxigênio aos 28 dias de vida. A incidência foi calculada dividindo-se o número de casos pelo total de prematuros de muito baixo peso das duas maternidades, durante o período do estudo. Foram feitas análises das variáveis associadas com o teste do Quiquadrado, para as categóricas, e o teste T de Student ou Mann-Whitney para as numéricas. Para prever o valor dessas variáveis foi realizada a análise de regressão logística. Resultados: foram admitidos nas duas instituições 244 prematuros de muito baixo peso. A incidência observada foi 22,1%. Destes, 54 evoluíram com a doença e 94 não a apresentaram. Houve diferenças quanto às médias de peso dos grupos (1050g com displasia e 1275g sem displasia) e quanto às médias de idades gestacionais (30 semanas com displasia e 32 semanas sem a doença). Fizeram uso de ventilação mecânica 94% dos prematuros com displasia e 45,8% sem displasia, com p<0,01. Também houve associação com uso de surfactante no grupo com displasia (98% com e 71,7% sem displasia, com p<0,01). O modelo de regressão logística foi preditivo em 70% para ventilação mecânica ao nascer (RR=2,04; IC 95%: 1,62-2,55) e peso ao nascer inferior a 1000g (RR=1,89; IC: 1,19-3,00). Conclusões: a incidência de DBP foi similar à encontrada na literatura. Houve associação com, baixa idade gestacional, uso de surfactante, baixo peso ao nascer e ventilação mecânica, sendo esses dois últimos preditivos para a doença.
Objectives: To determine the incidence of bronchopulmonary dysplasia in the period of one year (from March 2009 to February 2010) and analyze the associated neonatal risk factors to the development of the disease in Public Services in two references of high risk newborn in Maceió, the “Hospital Universitário Alberto Antunes” and the “Maternidade Escola Santa Mônica”. Methods: All very low birth weight preterm infants who were admitted in the both institutions were recorded during one year. The diagnosis was established in those preterm infants who needed oxygen at 28 days of life. The incidence was calculated by dividing the number of cases by the total number of preterm births in both hospitals during the study period. The associated variables were analysed with the “Chi-square” test and the T test of Student or Mann-Whitney. Logistic regression analysis was performed to predict the value of those variables. Results: 244 RNMBP were admitted in both institutions. The incidence was 22.1%. 54 evolved with bronchopulmonary dysplasia and 94 without. There were differences regarding the average weight of the groups (1050g with and 1275g without dysplasia)) and also as to the gestational age (30 weeks with BPD and 32 weeks without the disease). 94% of the prematures with and 45,8% without the disease made use of mechanical ventilation, with p<0,01. There were association with surfactant in the group with bronchopulmonay dysplasia (98% with and 71,7% without displasia, com p<0,01). The logistic regression model was predictive in 70% of mechanical ventilation at birth (RR=2,04 IC 95% 1,62-2,55) and weight lower than 1000g (RR=1,89 IC 95% 1,19-3,00).Conclusions: The incidence of DBP was similar to the literature. There were association with low weight in born, with low gestational age, use of surfactant and mechanical ventilation. Mechanical ventilation and weight lower than 1000g were predictive for the disease.
TEDE
BV UNIFESP: Teses e dissertações

La present tesi es centra en analitzar aquells factors que poden incidir en el desenvolupament cognitiu en infants prematurs o a terme, i que han requerit que fossin ingressats a una Unitat de Cures Intensives Neonatals (UCIN). S’incorporaren a l’estudi tots aquells infants nascuts entre l’1 de gener de 2001 i 31 de desembre de 2008, quedant una mostra de 440 nens de les següents edats gestacionals: prematurs extrems (n = 30), molt prematurs (n = 125), prematurs moderats (n = 124), prematurs tardans (n = 130), i a terme complerts (n = 31). S’avaluaven els nens entre les 34 i 46 setmanes d’edat postmenstrual amb l’Escala de Brazelton (NBAS), i es va fer un seguiment als 3, 6, 9, 12, 18, 24 i 30 mesos administrant les Escales Bayley, i en els 3, 4, 5, 6 i 7 anys amb els tests Terman-Merrill i WPPSI-III. Els objectius generals que es marcaren foren: (a) descriure la morbiditat, comorbiditat i seqüeles associades a l’infant i comparar-les en funció de variables sociodemogràfiques i clíniques, (b) descriure el desenvolupament des del naixement fins als 4 o 7 anys en funció de variables sociodemogràfiques i clíniques (c) determinar els factors de risc que influeixen al desenvolupament i la comorbiditat, i (d) determinar els factors protectors que influeixen al desenvolupament i la comorbiditat. S’ha trobat que: els nadons que han patit estrès a la UCIN tenen puntuacions de QI(z) més baixes al llarg del període estudiat; la toxicitat neurobiològica de l’estrès afecta a tots els nadons ingressats a la UCIN i pot ser contrarrestada per les Cures Centrades en el Desenvolupament i la Família (CCD); la reducció de la sobreestimulació lumínica s’ha manifestat amb una reducció de les retinopaties; els nadons que van patir algun dels elements que configuraven el factor de risc d’estrès a la UCIN, si no varen rebre les CCD tenen puntuacions en la NBAS menys elevades en els clústers sistema motor, regulació d’estats, i estabilitat del sistema nerviós autònom, i més elevada en l’organització d’estats; els nadons que no varen rebre les CCD tenen un risc moderat de patir trastorns de la regulació que es superior als que sí varen rebre les CCD. El curs de desenvolupament cognitiu està més marcat per les setmanes de gestació que pel pes i la patologia soferta; en les proves cognitives les nenes puntuen més alt, però els nens augmenten el seu QI(z) en major mesura que no pas les nenes; en l’infant de famílies amb baixos nivells econòmics i educatius es minva el seu QI(z) a partir de l’exploració en el període de 10 a 18 mesos endavant; el grup de procedència autòctons tenen una puntuació tipificada del QI una mica més elevada en l’índex de desenvolupament que els estrangers, i en els períodes d’avaluació la diferencia és significativa en els períodes de 19 a 30 mesos i 31 a 59 mesos; els nadons que prenen llet de fórmula són els que més augmenten el diferencial del seu QI(z) en l’índex de desenvolupament, però els que són alletats amb llet materna són els que tenen puntuacions més elevades de QI(z) en tots i cadascun dels períodes d’avaluació. Pel que respecta a la comorbiditat, els grups de procedència tenen associacions significatives amb els trastorn psicofuncionals, on els autòctons tenen més incidència, i el trastorn de la relació parental, on els estrangers pateixen més aquest trastorn. L’efecte de l’impacte negatiu en el desenvolupament cognitiu degut als factors socials apareix en el període de 10 a 18 mesos, com són els trastorns de la relació parental i el nivell socioeconòmic baix, i en els 19 a 30 mesos si els pare i/o mare són estrangers; en els nadons i les famílies hi ha una relació entre estar ingressat a la UCIN i patir trastorns de la relació parental; que un professional passi la NBAS davant els pares suposa que apareguin menys trastorn de la relació parental; els trastorns de la relació parental estan associats amb els trastorns psicofuncionals i els trastorns emocionals; a més visites efectuades en el PSD més detecció de trastorns psicofuncionals i de trastorns emocionals.
his thesis focuses on analyse the causes that can affect cognitive development in premature and full term new-borns who have been admitted to a Neonatal Intensive Care Unit (NICU). Also, in the study are included children born between the 1st January 2001 and the 31st December 2008, altogether it consists of a sample of 440 new-born babies from the following gestational age: extremely premature (n = 30), very premature (n = 125), moderate premature (n = 124), late premature (n = 130) and full term (n = 31). Evaluates children between the age of 34 and 46 post-menstrual weeks using the Brazelton Scale (NBAS). It then follows them up at 3, 6, 9, 12, 18, 24 and 30 months using the Bayley scales, and then when they are 3, 4, 5, 6 and 7 years old using the Terman-Merrill tests and the WPPSI-III. The main objectives to achieve were: (a) To describe morbidity, comorbidity and side effects associated with a child and then compare them based on clinical and socio-demographic variables; (b) to describe the development from birth up to 4 or 7 years of age based on clinical and socio-demographic variables; (c) to identify the risk factors that influence the development and comorbidity and; (d) to identify the protective factors that influence the development and the comorbidity. The results display that children who have suffered stress in a Neonatal Intensive Care Unit (NICU) have lower IQ scores (z) in the period of this study; the neurobiological toxicity caused by the stress affects all children admitted to the NICU, and it could be neutralised with healing based on physiological development and care, and assisting the family. For instance, reducing overstimulation of light has shown to reduce retinopathy; the children who suffered some elements of the stress risk factor in the NICU, if they did not have the Family-Focused Developmental Care (FFDC), were found to have had lower scores in the NBAS in the clusters motor system, regulation of states and stability of the autonomous nervous system and higher scores in the organization of states. It is also found that babies who did not receive the FFDC had a moderate risk of suffering from regulated disorders in comparison than those who received it. The course of cognitive development is more affected by the weeks of gestation than the weight and pathology. In cognitive tests, girls scored higher but boys increased their IQ(z) to a greater extent than girls. It was found that children in families with low economic and educational levels, had a decrease in the IQ(z) from the exploration to the period of 10 to 18 months. The locals had IQ scores slightly higher on the development index than foreigners, and the difference is significant between the periods of 19 to 30 months and 31 to 59 months. Concerning the comorbidity factor, local groups have significant associations with psycho-functional disorders while foreigners suffer more from parental relationship disorders. There are more chances for a baby to be breast-fed after being born if the baby has more weeks of gestation, for it gains more weight and consequently it has more protective factors. With less weeks of pregnancy, the risk factors are higher and the probability of artificial feeding increase. The effect of the negative impact on cognitive development is due to social factors, such as relationships and low socioeconomic status, that appear in the period of 10 to 18 months. Also, the impact of whether the one of the parents or both are foreigners appears between 19 to 30 months. There is a relationship between being admitted to the NICU and children and families that have disrupted parental relationship. The administration of the NBAS by a professional with the parents present, has resulted with less parental relationship disorder. Keeping in mind, disorders associated with parental relationships are fundamentally psycho-functional and emotional disorders. Thus, this study has shown the more visits to the Tracking Development Program the more detection of psycho- functional and emotional disorders.

General principles 38Parenteral nutrition 39Enteral feeding 40Developments in care for the premature newborn have lead to increasing survival (50% of infants born at 24 weeks gestation) and an increased awareness of the importance of nutrtional support. Many have difficulty tolerating enteral nutrition in the early weeks of life until gastrointestinal motility has matured. Some develop necrotizing enterocolitis (NEC) which carries a high risk of morbidity and mortality, and may be regarded as a failure of adaptation to postnatal life. Optimum nutrition should allow adequate growth in the short term, free of metabolic and other complications, with long-term fulfilment of both genetic growth and developmental potential....

Necrotizing enterocolitis (NEC) is a severe inflammatory bowel disease that commonly affects premature infants. The pathogenesis is multifactorial and poorly understood, although certain risk factors have been identified. This disease, more commonly detected in premature infants with accompanying cardiac and pulmonary comorbid conditions, is associated with increased morbidity and mortality. Multiorgan system homeostasis becomes critical for the pediatric anesthesiologist when approaching medical and surgical interventions for affected patients. This chapter focuses on the population at risk for developing necrotizing enterocolitis, medical and surgical management, providing anesthesia care in the neonatal intensive care unit, as well as perioperative considerations and complications.

Increased medical co-morbidity is one of the underlying causes of excess and premature mortality in bipolar disorder. This increased prevalence of medical conditions is likely to result from a range of different factors. Some attention in recent years has been devoted to intrinsic illness factors resulting in excessive allostatic load and oxidative stress potentially predisposing to physical morbidity. Some other contributors have also been identified as unhealthy lifestyle habits and unwanted effects of pharmacological treatment. Irrespective of causality, risk minimization can be obtained by systematically addressing physical needs into the management of bipolar disorder. This can be achieved with a range of interventions including regular monitoring of physical health, tailored management of unhealthy lifestyle choices, and pharmacological optimization.

Despite the advances in surgical techniques, very few ACHD patients have a truly curative procedure, with the majority being at lifelong risk of complications, including ventricular dysfunction, arrhythmias, and premature death. Ventricular dysfunction, leading to heart failure, remains a major cause of morbidity and mortality, with some studies showing that it accounts for up to 40% of deaths in adults with CHD. This chapter discusses drug therapy, transplantation, and end-of-life care in ACHD.

The UK government, in its White Paper in 1998, declared that ‘smoking is the greatest single cause of preventable illness and premature death in the UK’. Cigarette smoke is inhaled because it contains nicotine, which is highly addictive. Nicotine itself has some adverse physiological effects but it is mainly the 4000+ chemicals (including acetone, arsenic, paint stripper, pesticides, and over 60 known carcinogens), added to make the cigarette such an extremely potent nicotine delivery device, that cause so much damage.A smoker dies on average 8–10 years before a non-smoker does. The commonest causes of premature death in smokers are cardiovascular disease, lung cancer, and COPD. However, smoking also leads to much morbidity, causing or worsening many illnesses and affecting every system of the body. In addition, it is associated with a number of cancers, including lung cancer, nasopharyngeal cancer, laryngeal cancer, oesophageal cancer, stomach cancer, pancreatic cancer, colonic cancer, kidney cancer, bladder cancer, cervical cancer, and acute myeloid leukaemia. Stopping smoking at any age has been shown to improve health and increase life expectancy. Even with advanced smoking-related diseases, observational studies show clinically meaningful benefits in stopping smoking.

Necrotizing enterocolitis is a common and serous disease predominantly affecting premature newborns, with an incidence, morbidity, and mortality that has remained unchanged for several decades. Around 7% of infants between 500g and 1500g birth weight are affected, with the disease often manifesting with vomiting, bilious aspirates, distended abdomen, and blood in stools around 8–10 days of age. Medical management includes decompression of the gastrointestinal tract via a nasogastric tube, broad-spectrum antibiotics, and bowel ‘rest’ (total parenteral nutrition). Surgical intervention is required for intestinal perforation or ongoing deterioration despite medical management. The pathogenesis is multifactorial and includes genetic predisposition, gastrointestinal immaturity, imbalance in microvascular tone, abnormal intestinal microbiological colonization, and a highly immunoreactive intestinal mucosa. Breast milk feeds appear to confer some degree of protection.

What are the teachings of the major world religious traditions about the status and care of the premature or sick newborn? This question becomes important in the context of neonatal intensive care units (NICUs) committed to the ideals of family-centered care, which encourages shared decision making between parents and NICU caregivers. In cases of infants with conditions marked by high mortality, morbidity, or “great suffering,” family-centered care affirms the right of parents to assist in decisions regarding aggressive treatment for their infant. But while there is evidence that families’ religious beliefs often profoundly shape their approach to medical decision making, few studies have tried to understand what major religious traditions teach about the care of the newborn or how these teachings may bear on parents’ decisions. This volume seeks to address this need, providing information on religious teachings to the multidisciplinary teams of NICU professionals (neonatologists, advance practice nurses, social workers), parents of NICU patients, and students of bioethics. In chapters dealing with Judaism, Catholicism, Denominational Protestantism, Evangelical Protestantism, African American Protestantism, Sunni and Shi’a Islam, Hinduism, Buddhism, Navajo religion, and Seventh-day Adventism, leading scholars develop the teachings of these traditions on the status, treatment, and ritual accompaniments of care of the premature or sick newborn.

Five types of morbidity and mortality have been identified as the main health expressions of health harm associated with illicit drug use: 1) overdose; 2) other injury; 3) non-communicable physical disease; 4) mental disorders; and 5) infectious disease. Burden of disease estimates combining years of life lost due to premature mortality and disability indicate that illicit drugs ranked eighth among causes of disease, death, and disability in developed regions of the world. Opioids, cocaine, and amphetamines entail greater risks, especially when they are injected. Many harmful consequences are not completely intrinsic to the properties of the drug, but instead are associated with the physical and social environment in which drug use takes place. These epidemiological considerations need to be taken into account in the allocation of resources for prevention programmes, treatment, and social services.

Mental health is critical to personal well-being, interpersonal relationships, and successful contributions to society. Mental health conditions consequently impose a high burden not only on individuals, families and society, but also on economies. In Jamaica, mental health conditions are highly prevalent and major contributors to morbidity, disability, and premature mortality. Encouragingly, with timely and effective treatment, individuals suffering from mental health conditions can lead productive and satisfying lives. This publication, the first of its kind, provides evidence and guidance to support the development, financing, and implementation of mental health interventions in Jamaica. Specifically, it estimates the return on investment (ROI) from scaling up treatment for anxiety, depression, and psychosis. The results from this analysis show that Jamaica can significantly reduce the health and economic burden of mental health conditions by investing in cost-effective recommended interventions designed to improve mental health.

There is a bidirectional relationship between depression and type 2 diabetes (T2D). Patients with comorbid depression and T2D are at high risk of complications and premature mortality. Conventional treatments for depression do not consistently improve diabetes outcomes, despite improving depressive symptoms. Shared mechanisms may underpin both depression and T2D, providing novel pharmacological targets to treat both conditions simultaneously. There are several candidate pathways. For inflammation and vitamin D deficiency, there is good cross-sectional evidence to support an association with depression in T2D. Prospective epidemiological studies are needed to test biological pathways as predictive biomarkers of depression and T2D. Intervention studies are needed to test the modifiability of these pathways. Repurposing of established diabetes treatments may provide a ‘multiple hit’ strategy. The identification and modification of novel biological targets has the potential to treat both depression and T2D, as well as reducing longer term morbidity and mortality.

In recent years an increase in premature births (PB) rate has been noticed, as this pregnancy complication that still remain an important cause of perinatal morbidity and mortality, is multifactorial and prediction is not easy in many cases. There are many bibliographic data supporting the view that PB have also genetic predisposition. The trend of “recurrence” of PB in women as well as its increased frequency in ethnic groups suggests its association with genetic factors, either as such or as an interaction of genes and environment. Immunomodulatory molecules and receptors as well as polymorphisms of various genes and/or single nucleotides (single nucleotide polymorphisms, SNPs) now allow with advanced methods of Molecular Biology the identification of genes and proteins involved in the pathophysiology of PB. From the history of a pregnant woman, the main prognostic factor is a previous history of prematurity, while an ultrasound assessment of the cervix between 18 and 24 weeks is suggested, both in the developed and the developing world. According to the latest data, an effective method of successful prevention of premature birth has not been found. The main interventions suggested for the prevention of premature birth are the cervical cerclage, the use of cervical pessary, the use of progesterone orally, subcutaneously or transvaginally, and for treatment administration of tocolytic medication as an attempt to inhibit childbirth for at least 48 hours to make corticosteroids more effective. Despite the positive results in reducing mortality and morbidity of premature infants, the need for more research in the field of prevention, investigation of the genital code and the mechanism of initiation of preterm birth is important.

Women account for roughly 90% of patients with systemic lupus erythematosus (SLE) and they are typically diagnosed when they are in their childbearing age. Patients with SLE are at increased risk of premature cardiovascular disease (CVD) representing the major cause of morbidity and mortality in this patient group. Premature CVD is significantly pronounced in women with SLE who have a history of pre-eclampsia compared to those who have no history of pre-eclampsia. Therefore, the prevention of future CVD is particularly important in women with a previous pregnancy history complicated by pre-eclampsia. Patients worry about the possible risk for future CVD.

Women account for roughly 90% of patients with systemic lupus erythematosus (SLE) and they are typically diagnosed when they are in their childbearing age. Patients with SLE are at increased risk of premature cardiovascular disease (CVD) representing the major cause of morbidity and mortality in this patient group. Premature CVD is significantly pronounced in women with SLE who have a history of pre-eclampsia compared to those who have no history of pre-eclampsia. Therefore, the prevention of future CVD is particularly important in women with a previous pregnancy history complicated by pre-eclampsia. Patients worry about the possible risk for future CVD.

High blood pressure (hypertension) is arguably the most important preventable cause of premature microvascular and macrovascular disease and the associated morbidity and mortality in people with diabetes. This chapter will review key aspects of the epidemiology and pathophysiology of hypertension in people with diabetes, as well as recommended approaches to its clinical evaluation and treatment.

Antiphospholipid syndrome (APS) is characterized by arterial and/or venous thromboses and/or obstetric morbidity in patients persistently positive for moderate to high titres of antiphospholipid antibodies (aPL) according to the current classification criteria. Pregnancy morbidity includes unexplained consecutive recurrent 1st trimester pregnancy loss (<10 weeks’ gestation), any 2nd or 3rd trimester pregnancy loss, premature birth before 34 weeks of gestation due to conditions associated with ischemic placental dysfunction including severe pre-eclampsia, eclampsia, foetal growth restriction, and intrauterine death. Current treatment to prevent obstetrical morbidity is based on low-dose aspirin and/or low molecular-weight heparin and has improved pregnancy outcomes to achieve successful live birth in >70% of pregnancies. Although hydroxychloroquine and pravastatin might further improve pregnancy outcomes, prospective clinical trials are required to confirm these findings.

Type 2 Diabetes Mellitus (T2DM) is a noncommunicable, lifestyle-related chronic metabolic disorder of global involvement, characterized by elevated blood sugar levels, manifested by hyperglycaemia, polyuria, polydipsia and polyphagia. DM is associated with acute and chronic complications which lead to reduced quality of life, premature morbidity and mortality. T2DM is linked with overweight, obesity, reduced physical activity and a genetic component. T2DM is named a silent killer because the primary disease is silent at the early stage and usually gets diagnosed when presenting with a vascular event such as stroke or heart attack. Impaired cardiorespiratory fitness plays a crucial role in acceleration of cardiovascular complications resulting in premature organ damage, morbidity and mortality. Regular physical activity, resistance training and reduction in sedentary life style along with diet control and drugs help to control DM and prevent or delay complications. This chapter deals with diabetes as a disease, its prevalence, risk factors, signs and symptoms, pathophysiology, pathogenesis and underlying mechanisms, acute and chronic complications, along with measures to enhance cardiorespiratory fitness and control DM and a word of caution to the younger generation to be aware of the silent killer.

Extreme prematurity is the leading cause of infant death and morbidity. And, despite advances in neonatal medicine and surgery, the rate of prematurity has risen. The urgent need for a better way to support the extremely premature infant led to the development of an extrauterine system to better bridge the transition from fetal to postnatal life. The goal of this “artificial womb” is to maintain prenatal physiology in the extremely premature neonate to support normal development and reduce the complications associated with prematurity. This chapter discusses the development and applications of the artificial womb, as well as the limitations of this technology. It explores three current ethical challenges: ectogenesis, the boundary of viability, and the difference between physiological and clinical success.

Inflammation, a vital defense mechanism for health, is defined as the immune system's response to harmful stimuli such as pathogens, damaged cells, toxic compounds or irradiation. Inflammation is usually examined in two groups: acute and chronic. Chronic inflammation instigates various kinds of diseases that cause premature mortality and morbidity such us cardiovascular diseases, cancer, diabetes mellitus (DM), asthma-chronic obstructive pulmonary disease (COPD), obesity, metabolic syndrome (METs), inflammatory bowel disease (IBD), rheumatoid arthritis (RA), multiple sclerosis (MS), osteoporosis, and neurological diseases via dysregulation of various signaling pathways such as nuclear factor kappa-B (NF-κB), signal transducer, activator of transcription 3 (STAT3), etc. These inflammation-related diseases are among the major causes of mortality and morbidity in almost every region of the world. Studies have shown that these diseases associated with inflammation have tended to increase worldwide.

It is well recognized that both Intellectual Disability (ID) and epilepsy individually have higher rates of premature mortality. Thus, the two conditions in combination will be more likely to lead to premature mortality than either individually. People with ID and epilepsy have a higher likelihood of communication, psychiatric, behavioural, and drug sensitivity problems that makes their treatment difficult. This is not a homogenous group. At one end of the spectrum are patients with mild ID, 10–12% of who have epilepsy and treatment is mainly focused on areas like compliance and risky behaviours. At the other end are patients with severe ID, up to 50% of who have epilepsy and treatment is more focused on factors such as the co-morbidity, impact of medications, recognition of side effects, treatment resistance, and informed consent. This chapter looks to collate and provide an overview of epilepsy diagnosis and management and the current good practice on its applicability to people with ID.

Coronary Artery Disease is one of the leading causes of deaths worldwide, with an estimated 7.2 million deaths each year. In spite of the improvements in imaging and other diagnostic modalities, the incidence of premature morbidity and mortality is still very high, the main reason being the lack of accurate in-vivo and in-vitro patient-specific estimates for diagnosis and disease progression. Recently, CFD-based models have been proposed for analyzing the coronary circulation [1, 2]. The main challenges for such methods are the lack of patient-specific data (anatomy, boundary conditions), inefficient multi-scale coupling and computational resources. These challenges limit the scope of such methods in a routine clinical setting.

Hundreds of thousands of injuries to ligaments, tendons or the joint capsule occur in the U.S. each year, resulting in significant reduction of quality of life for many patients [1]. Existing reconstruction techniques for torn tendons/ligaments result in significant morbidity and cannot fully recapitulate the native joint biomechanics, leading to secondary degeneration over time, such as premature osteoarthritis. Thus, tissue-engineered alternatives to current grafts, potentially using stem cells in combination with an appropriate scaffold, are greatly needed. In response, our laboratory is investigating a novel hydrogel system and a custom tensile bioreactor as an in-vitro model to study the formation of both fibrous (ligament) tissue and the ligament-bone interface. In these studies, we examine the effect of tensile loading and the degradability of the surrounding environment on cellular morphology and tendon/ligament extracellular matrix (ECM) production by mesenchymal stem cells (MSCs). In particular, the response of MSCs embedded within hydrogels with varying degrees of susceptibility to degradation by collagenase is explored. In addition, proof-of-principle experiments are presented to extend this system to examine the effect of co-culture of multiple cell types on differentiation of MSCs in a milieu that mimics the bone-ligament insertion.

Review question / Objective: To systematically synthesize the key characteristics (the reach, implementation, efficacy, and safety) of digitally delivered fall and fracture prevention through exercise among community-residing older adults. Rationale: Falls represent a significant cause of preventable injury, contributing to premature morbidity and mortality worldwide(1). Fall risk is multifactorial, and there are numerous strategies to prevent falls, being exercise programs strongly recommended. While there is strong evidence of the effectiveness of targeted exercise in reducing falls and fractures in older adults (2), these are normally delivered in-person by qualified instructors. With the COVID-19 pandemic, the use of technologies for medical care increased substantially(3). Also, services including exercise programs were shut down. The combination of continued reluctance among many older adults to return to in-person programs in addition to their comfort level to exercise from their homes are two main factors that justify the need for digitally delivered programs. To date, little is known about the reach, implementation, efficacy, and safety of exercise programs delivered digitally.