NAIL SIGNALS

The nails are brilliant tips adorning our fingers. They provide lots of tips on the overall health of the owner. Our nails are built from keratin proteins and generally grow at the rate of  1mm per month. The nails just like the hairs belong together and could send signals as to the health or diseased nature of our bodies. The following are points to ponder.

PLACENTAL TRANSFUSION

Move slowly – Prolonged placental transfusion stabilizes preterm newborns

Puran Falaturi

(Photo: iStock.com/MedicalArtInc)

The optimal moment for clamping the umbilical cord is a recurrent subject of discussion. Early clamping allows for immediate transfer of the infant to the neonatologist. Later clamping, however, results in a prolonged placental transfusion which improves peripartum circulation and so can have other positive outcomes for the newborn (1) (2). This is true for full-term as well as for preterm neonates. For premature infants, however, interventions that can have an additional stabilizing effect are far more urgent.

Examples of improved outcomes that can result from prolonged placental transfusion include a lower incidence of intraventricular hemorrhages (IVH), a higher birth weight, better hemoglobin concentration and larger iron reserves up to six months after birth. As a result of the large volume and the higher hemoglobin (Hb) values, infants with later umbilical clamping require fewer erythrocyte transfusions (2, 3, 4, 5). Hyperbilirubinemia that requires phototherapy and hypothermia were described as negative concomitant phenomena in several studies (1, 2), but were not confirmed in all studies.

Reviews and meta-analyses

Several reviews with meta-analyses have been published on this subject. Some of these focus on preterm and extremely preterm newborns. Rabe et al. (1) updated a Cochrane Review in 2012 on the comparison of early and late clamping in premature infants. The authors searched the study registry of the Cochrane Pregnancy and Childbirth Group through June 2012. The age of the included neonates was between 24 and 36 weeks gestational age. The review included randomized controlled studies that compared early and delayed clamping and other procedures for prolonged placental transfusion. Fifteen studies (738 infants) could be included.

The results of the Cochrane Review showed a maximum period until clamping of 180 seconds. Delayed clamping was associated in seven studies with 392 infants with significantly fewer blood transfusions (risk ratio (RR) 0.61). In ten studies with a total of 539 infants, there were significantly fewer sonographically confirmed intraventricular hemorrhages independent of the degree of severity (RR 0.59). Five studies with a total of 241 children found a lower risk of necrotizing enterocolitis (NEC with delayed clamping (RR 0.62). However, the bilirubin peak in infants with delayed clamping was significantly higher than in the controls (seven studies, 320 children, mean difference 15.01 mmol/L). Most of the other outcomes including mortality rate, serious intraventricular hemorrhages and PVL did not show any clear differences. There were no significant differences between the groups in the mean Bayley II Score at the corrected age of seven months (58 children). None of the studies reported about outcomes for the mothers.

Ghavam et al. (4) showed in a 2014 review that delayed clamping and postpartum cord milking in extremely low birth weight (ELBW) infants under 30 weeks (<1000g) had many short-term benefits. They analyzed literature up to December 2012. Ten of 19 identified studies were included (n = 199). Neurological development disorders in the sense of a disability were not significantly increased at an age of 18 and 24 months. But there were short-term benefits such as better blood pressure and hemoglobin values and with this a reduced need for blood transfusions.  In addition, the researchers found a trend towards fewer intraventricular hemorrhages and less late onset sepsis.

Current clinical studies confirm benefits

In both reviews, the researchers concluded that further clinical studies should be conducted in future. A quite recent publication has come from neonatologists in the USA in 2016 (the Bolstridge study) (5). This publication compares two cohorts with infants who were born prior to gestational week 37 (level 3 hospital, 52 beds). Only very low birth weight (VLBW) infants were included in the analysis. Cohort 1 consisted of 136 children who were born prior to the recommendation for delayed clamping and were more or less immediately clamped (exception 0.7 percent). The observation period extended from 1 July 2012 to 30 June 2013. Cohort 2 included 142 infants born in the period from 1 July 2013 to 30 June 2014 after the implementation of the recommendation for delayed clamping. This occurred independent of umbilical cord management since all of the newborns were also participating in the quality improvement program, and so the data for all the births was included. In total, 72 percent of the children in Cohort 2 had delayed cord clamping.

Results

The sociodemographic data, mortality and Apgar scores did not differ between the two groups. Significant differences in favor of delayed clamping were found in connection with intubation, chest compressions, erythrocyte transfusion, ventilation, CPAP and late onset sepsis (see Table 1). The researchers found no differences between the two groups regarding the incidence of IVH of any degree, PVL, early onset sepsis, NEC or the necessity of inotropic support during the hospital stay. Important to note is the fact that in contrast to previous study results the potentially negative effects of hypothermia and hyperbilirubinemia requiring phototherapy did not increase.

Interpretation

The authors remark that the apparent causality observed between umbilical cord management and reduced need for intubation and chest compression should be viewed cautiously. At the same time as the study, the hospital was implementing a policy of more restrictive ventilation management to reduce the rate of BPD. This could be a reason for the significantly lower figures. However, the reduced rate in CPAP ventilation cannot be explained by the new ventilation management policy. This could more likely be attributed to the delayed clamping. The statistical power of the study was not sufficient for relatively rare disorders such as NEC and PVL.

Conclusion

Both reviews come to the conclusion that prolonged placental transfusion can improve the short-term outcome of ELBW neonates. Rabe et al. (1) state more precisely that prolonged placental transfusion through delayed clamping (30 to 120 seconds) seems to be accompanied by lower need for transfusion, better cardiovascular stability, less intraventricular hemorrhage (all degrees) and a lower risk of NEC. However, the data basis was not sufficiently reliable for definite recommendations. The data basis regarding neurological development disorders and safety aspects is very thin according to Ghavam et al. (4). For that reason, additional well designed RCTs should be made on this subject. The authors of the Bolstridge study (5) emphasize the relevance of having a multidisciplinary and well-trained team so that the best measures can also be successfully implemented. Negative concomitant phenomena such as hyperbilirubinemia and hypothermia could not be consistently confirmed and need to be reviewed. However, in relation to the benefits of delayed clamping, these negative factors are less significant.

Sources:

1. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T, Cochrane Database Syst Rev, 2012 Aug 15;(8):CD003248. doi: 10.1002/14651858.CD003248.pub3, „Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes.“
   http://bit.ly/2hnXqEW
2. Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B, European Resuscitation Council (ERC), Notfall Rettungsmed 2015, 18:964–983, DOI 10.1007/s10049-015-0090-0, Online publiziert: 9. November 2015, Die Versorgung und Reanimation des Neugeborenen, Kapitel 7 der Leitlinien zur Reanimation 2015 des European Resuscitation Council
   http://www.guidelines2015.com/
3. McDonald SJ, Middleton P, Dowswell T, Morris PS, Cochrane Review Gruppe:  Pregnancy and Childbirth Group, 11. Juli 2013, The Cochrane Library, First published: 11 July 2013, DOI: 10.1002/14651858.CD004074.pub3View/save citation, „Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.“
4. Ghavam S, Batra D, Mercer J, Kugelman A, Hosono S, Oh W, Rabe H, Kirpalani H, Transfusion. 2014 Apr;54(4):1192-8, „Effects of placental transfusion in extremely low birthweight infants: meta-analysis of long- and short-term outcomes.“
   https://www.ncbi.nlm.nih.gov/pubmed/24843886
5. Bolstridge J, Bell T, Dean B, Mackley A, Moore G, Swift C, Viscount D, Paul DA, Pearlman SA, BMC Pediatr. 2016 Sep 13;16(1):155. doi: 10.1186/s12887-016-0692-9, „A quality improvement initiative for delayed umbilical cord clamping in very low-birthweight infants.“
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022231/
6. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee opinion no. 543: Timing of umbilical cord clamping after birth. Obstet Gynecol. 2012;120:1522–6
   http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Timing-of-Umbilical-Cord-Clamping-After-Birth
7. AAP Empfehlungen 2015, Part 13 Neonatal Resuscitation, No. 3 Umbilical Cord Management 
   https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-13-neonatal-resuscitation/     COPIED.

Out break of Cerebrospinal Meningitis

Forwarded on the instruction of HCH Dr Idris. Pls lets kindly alert our DSNOs
Please note this alert and get your facilities ready and staff sensitized on this urgently. Also forward this to all your colleagues.

FG Advises on Meningitis, Affects 16 States
As the new strain of Cerebrospinal Menigitis (CSM), Neisseria Meningitides type C continues to spread in epidemic proportion for the first time in Nigeria, federal government has issued a public advisory urging key prevention mechanisms. Meningitis is an acute inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. The most common symptoms are fever, headache and neck stiffness. Other symptoms include confusion or altered consciousness, vomiting, and an inability to tolerate light or loud noises.
Meningitis - Wikipedia
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Meningitis Clinical Presentation: History, Physical Examination, Complications
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Feb 16, 2016 - In a large prospective study of 696 cases of adults with bacterial meningitis, van de Beek et al reported that 95% of the patients had 2 out of the following 4 symptoms: fever, headache, stiff neck, and altered mental status. Other symptoms can include the following: Nausea. Vomiting.
Patients with aseptic meningitis syndrome usually appear clinically nontoxic, with no vascular instability. They characteristically have an acute onset of meningeal symptoms, fever, and CSF pleocytosis that is usually prominently lymphocytic.

When this happens, CSF findings may resemble those of viral meningitis, but antibiotic treatment may need to be continued until there is definitive  ...
‎Meningococcal disease · ‎African meningitis belt · ‎Meningococcal vaccine · ‎Hib
Meningitis Symptoms and causes - (Mayo clinic) Comprehensive overvi
Among the prevention mechanisms advised by Health Minister, Prof Adewole are:
•Avoidance of overcrowding
•Sleeping in well ventilated places
•Avoidance of close and prolonged contact with a case/s
•Proper disposal of respiratory and throat secretions
•Strict observance of hand hygiene and sneezing into Elbow joint/sleeves
•Reduce hand shaking, kissing, sharing utensils or medical interventions such as mouth resuscitation
•Vaccination with relevant sero-type of the meningococcal vaccine and
•Self-medication should be avoided.
According to the Minister, the country is currently experiencing an outbreak of Cerebrospinal Meningitis (CSM) that has spread across the country and mostly affecting States in the upper parts of the country which fall within the African Meningitis Belt.
Other Countries that are facing similar outbreaks at the moment include our West-African Neighbours like Niger, Chad, Cameroun, Togo, and Burkina Faso.
The larger African Meningitis Belt consists of 26 Countries that stretch from Senegal, Gambia and Guinea Bissau in the west coast to eastern countries of Eritrea and Ethiopia
He noted that this is not the first time or the worst Epidemic ever faced by Nigeria but this round of the epidemic has come with a difference, as all previous epidemics were caused by Neisseria Meningitides type ‘A’ but this year we are recording Neisseria Meningitides type C in epidemic proportion for the first time.
In the past, the worst CSM epidemics experienced in Nigeria occurred in 1996 when about 109,580 cases and 11,717 deaths were recorded, followed by the one in 2003 (4,130 cases and 401 deaths) then in 2008 (9,086 cases and 562 deaths) and in 2009, when 9086 cases and 562 deaths were recorded.
Following the successive outbreaks, the World Health Organisation(WHO) institutued the mass vaccination campaign using a new conjugate vaccine the MenAfriVac-A in about 16 out of the 26 Vulnerable countries (including Nigeria). It resulted in a reduction of over 94% incidence of the disease in most countries, thus significantly reducing the risk of type A.
Some key lessons learnt from the MenAfriVac-A mass vaccination campaign and the recent happenings across the sub-region, are that, although type A was successfully displaced, other strains which were hitherto less significant can actually assume epidemic proportions.
Thus Efforts must continue towards preventing a rebound of the type-A and also preventing a potential replacement by all other strains, said the Minister.
 Current Situation in Nigeria
As at Friday, March 31, Ninety (90) Local Government Areas (LGAs) in Sixteen (16) States of the Federation are so far affected including Zamfara, Katsina, Sokoto, Kebbi, Niger, Nassarawa, Jigawa, FCT, Gombe, Taraba , Yobe, Kano, Osun, Cross Rivers, Lagos and Plateau have been affected by the new strain of CSM.
A total number of 2524 people have been reportedly affected while death toll has risen to 328 Deaths. So far, a total 131 samples have been confirmed in the Laboratory, out of which a majority are Neisseria Meningitides type C. This current outbreak started in Zamfara State in the 50th week of 2016 (i.e. November 2016)
 Actions so far taken:
Control team constituted to coordinate all responses aimed at controlling the outbreak. Membership include FMOH, NCDC, NPHCDA, WHO and other partners (MSF, UNICEF, CDC and EHealth Africa):
Coordination meetings hold regularly; All initial five States have commenced Emergency Operation Center EOC/EPR meeting; Mapping of resources at State level to identify ongoing activities.
Case Management and Infection Prevention & Control (IPC):
•Functional Isolation centers/units have been identified in all States and efforts are on to strengthen them.
•Antibiotics and management supplies available and being used as per protocol in all States for treatment
•Number of cases currently on admission or treated since the onset of the outbreak are being collated across LGAs and States.
•Micro plan concluded in Zamfara for possible vaccination in week 14
Surveillance:
•Active case searches in the affected LGAs and register review ongoing
•Outbreak/rumour investigations ongoing
•Clinician sensitization and training proposed in selected area
•CSM guidelines including Laboratory protocol under review.
 Laboratory:
•Lumber puncture kits provided by WHO with plans for additional local sourcing.
•Pastorex used for testing CSF samples in the field (total of 131 cases positive) in all States
•Public health in Lagos State supporting with culture of positive samples from states.
•MSF facilitating sample analysis in Oslo by PCR
•Some PCR/Culture results are pending
Communication and Social Mobilization:
•Community health education is ongoing as part of State team responses with support from UNICEF
•Most States (especially Katsina and Zamfara) are doing radio jingles with support from UNICEF
•IEC materials are being developed by NCDC, NPHCDA and UNICEF
Challenges:
•Low CSF collection rates (CSF sample versus reported cases)
•Weak logistics for sample transportation for prompt laboratory diagnosis
•Weak coordination between SMOH surveillance officers and treatment Centres, and delayed reporting of suspected cases to National level.
•Weak/non-functional EPR committees in some States and LGA levels
•Low availability of supplies (Ceftriaxone, Lumber Puncture Kits, TI media etc.) at the national level
Next Steps:
•Update CSM surveillance and management data base especially for States with scanty epidemiological data
•Dissemination of targeted IEC materials to frontline health care workers in all States
•Redistribution of the treatment Antibiotic from non-active to actively reporting states to enhance case management
•Reactivate EPR committees at State and LGA levels in all States
•Support Katsina and Sokoto on preparation of ICG request
•Conduct detailed investigation on cases of Men-A in Zamfara and Katsina States
•Preparation for 2017/2018 CSM season to commence by October 2017. Very Important consideration shall be given to a Vaccine with wider spectrum of Antigens
•Arrange for cross border surveillance locally in Nigeria and internationally with Republic of Niger and Benin
Early Diagnosis, Treatment and Isolation:
•Very important that all individuals should acquaint themselves with at least the basic knowledge/understanding of CSM and how it is transmitted and prevented
•Strictly adhere to the advice of Health workers on how to protect oneself as enumerated above
•Prompt seeking for medical/health care as soon as CSM or CSM-Like Illness is suspected
•All Hospitals to ensure that appropriate Diagnoses are made including laboratory confirmation and immediate reporting through the surveillance system
•Commence early treatment as soon as the diagnoses of CSM is made
•Restrict mingling with other people once one is diagnosed as a case of CSM
•All Secondary and Tertiary Public Health Facilities should provide free treatment to all CSM Patients
The Federal Ministry of Health has allayed fears among Nigerians saying, “the public should remain calm as the disease Cebro-spinal Meningitis (CSM) is both preventable and curable”.
It however alerted that the cumulative number of people and locations affected may continue to increase but the actual rate of increase has begun to decline in some states indicating that the end of the epidemic is in sight.
Public health facilities have been directed to provide free treatment for all Cases of Cerebrospinal Meningitis.
It said more doses of the CSM vaccines are currently being expected in the country to be deployed to all affected states while available vials are being deployed to Zamfara, Sokoto, Katsina and FCT.