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\"It struck in the wake of World War II, a mysterious disease that killed almost 90 percent of those infected. A few of the survivors gained extraordinary powers while others were blighted with severe disabilities. Some of those afflicted chose to use their new abilities to help the human race. But some took a different path. In Aces high, it's the 1980s, but a 1980s both like and unlike our own. Now, after centuries of travel through space, an extraterrestrial being called the Swarm is headed for Earth. Meanwhile, some of the aces given superpowers by the virus are hatching conspiracies to control the human world. These factions are about to collide ... and the fallout could be catastrophic\"--Page 4 of cover.

Despite marked regional variation in the availability of neonatal intensive care, it is not known whether the supply of neonatologists or neonatal intensive care beds is associated with neonatal mortality. This retrospective cohort study involved almost 3.9 million U.S. infants with a birth weight of 500 g or greater who were born in 1995. As compared with infants born in regions with a very low supply of neonatologists (2.7 per 10,000 births), those from regions with a low supply of neonatologists (4.3 per 10,000 births) were less likely to die in the first 27 days of life. However, further increases in the supply of neonatologists were not associated with greater reductions in risk. Neonatal intensive care has reduced the mortality rate among newborns as the result of both technological advances and the advent of neonatal intensive care units. 1 , 2 Advances in neonatology have been accompanied by a dramatic increase in the number of neonatal intensive care units and neonatologists. 3 – 5 Thirty years ago, these resources were scarce and were primarily confined to university medical centers. Now, they are widely distributed and are available at hospitals that are close to and compete directly with tertiary care centers. 6 , 7 The benefits afforded by these increasing resource levels have not been established. 3 A larger supply of . . .

Background The first minutes after birth are critical to reducing neonatal mortality. Helping Babies Breathe (HBB) is a simulation-based neonatal resuscitation program for low resource settings. We studied the impact of initial HBB training followed by refresher training on the knowledge and skills of the birth attendants in facilities. Methods We conducted HBB trainings in 71 facilities in the NICHD Global Network research sites (Nagpur and Belgaum, India and Eldoret, Kenya), with a 6:1 ratio of facility trainees to Master Trainers (MT). Because of staff turnover, some birth attendants (BA) were trained as they joined the delivery room staff, after the initial training was completed (catch-up initial training). We compared pass rates for skills and knowledge pre- and post- initial HBB training and following refresher training among active BAs. An Objective Structured Clinical Examination (OSCE) B tested resuscitation skill retention by comparing post-initial training performance with pre-refresher training performance. We identified factors associated with loss of skills in pre-refresher training performance using multivariable logistic regression analysis. Daily bag and mask ventilation practice, equipment checks and supportive supervision were stressed as part of training. Results One hundred five MT (1.6 MT per facility) conducted initial and refresher HBB trainings for 835 BAs; 76% had no prior resuscitation training. Initial training improved knowledge and skills: the pass percentage for knowledge tests improved from 74 to 99% ( p  < 0.001). Only 5% could ventilate a newborn mannequin correctly before initial training but 97% passed the post-initial ventilation training test ( p  < 0.0001) and 99% passed the OSCE B resuscitation evaluation. During pre-refresher training evaluation, a mean of 6.7 (SD 2.49) months after the initial training, 99% passed the knowledge test, but the successful completion rate fell to 81% for the OSCE B resuscitation skills test. Characteristics associated with deterioration of resuscitation skills were BAs from tertiary care facilities, no prior resuscitation training, and the timing of training (initial vs. catch-up training). Conclusions HBB training significantly improved neonatal resuscitation knowledge and skills. However, skills declined more than knowledge over time. Ongoing skills practice and monitoring, more frequent retesting, and refresher trainings are needed to maintain neonatal resuscitation skills. Trial registration ClinicalTrials.gov Identifier: NCT01681017 ; 04 September 2012, retrospectively registered.

Almost 2000 programmes worldwide submitted proposals calling for “solving society's biggest problems with bold yet meaningful, verifiable, durable and feasible solutions” with an emphasis on people with disabilities, gender equity, and communities of interest, including potential beneficiaries who might suffer harm if their problems were not addressed immediately.1 The winning proposal, from Sesame Workshop and the International Rescue Committee, is committed to a shared belief that educating children displaced by conflict and persecution, languishing in the destroyed and refugee burdened region of Syria, Iraq, Jordan, and Lebanon, offers the best opportunity to save and cultivate an entire generation in the Middle East. The programme intends to implement an “evidence-based, early childhood development intervention to educate and improve children's learning outcomes today and their intellectual and emotional development over the long term”.1 The MacArthur Foundation recog-nises the strength of the combination of Sesame Workshop's Sesame Seeds experience in developing local education versions of Sesame Street in Bangladesh, India, Afghanistan, and South Africa for children and families that includes healthy habits and hygiene in the target group of children aged 0–8 years. The MacArthur Foundation and International Rescue Committee's more than 83-year history of helping to restore health, safety, education, and economic wellbeing in refugee communities through their global network of community workers will ensure that education is prioritised in humanitarian settings for the first time.2 MacArthur President, Julia Stasch, emphasised that the project, which is the largest ever created for children in a humanitarian setting, also addresses the longstanding problem that “less than 2% of the humanitarian budget is dedicated to education, and only a sliver of all education assistance benefits young children.”

We report and illustrate a case of fetal demise at 31 weeks caused by fulminant herpes simplex virus (HSV) infection. The 15-year-old mother reported no past history or symptoms of an HSV infection during pregnancy. Autopsy revealed extensively ulcerated skin and necrosis of the liver, adrenal glands, brain, and placental membranes. Fluorescent in situ hybridization studies of the lungs, liver, adrenal glands and placenta were positive for HSV, but did not distinguish between HSV-1 and HSV-2. A maternal postpartum blood sample was positive for HSV-2 by immunoblot assay.

To the Editor: The article by Goodman et al. (May 16 issue) 1 and the accompanying editorial by Grumbach 2 criticize what these authors interpret as excessive concentrations of neonatologists in response to profit-maximizing behavior by hospitals — proof that there are too many specialists. However, a casual inspection of the maps in Figure 1 of the article reveals that most areas with high ratios of neonatologists to neonates are not hotbeds of health care competition but, rather, sparsely populated regions of the country, such as Alaska, Appalachia, northern Maine, western Texas, and the Dakotas. These higher ratios do not represent an . . .

We carried out a multicenter randomized, placebo-controlled trial to evaluate the efficacy and safety of surfactant in the treatment of respiratory distress syndrome. The study population was made up of newborn infants weighing 750 to 1750 g who were receiving assisted ventilation with 40 percent or more oxygen. The eligible infants received a single dose of either surfactant (100 mg of phospholipid per kilogram of body weight [4 ml per kilogram]) or an air placebo (4 ml per kilogram), administered into the trachea within eight hours of birth by an investigator not involved in the clinical care of the infant. When compared with the infants who received the placebo(n = 81), the infants who were treated with surfactant (n = 78) had a 0.12 greater average increase in the ratio of arterial to alveolar oxygen tension (P<0.0001), a 0.20 greater average decrease in the fractional inspiratory oxygen concentration (P<0.0001), and a 0.26-kPa greater average decrease in the mean airway pressure (P<0.0001) during the 72 hours after treatment. Pneumothorax was less frequent among the infants treated with surfactant than in the control group (13 percent vs. 37 percent; P = 0.0005). There were no statistically significant differences between the groups in the proportion of infants in each of five ordered clinical-status categories on day 7 (P = 0.08) or day 28 (P = 0.75) after treatment. There were also no significant differences between the groups in the frequency of bronchopulmonary dysplasia, patent ductus arteriosus, necrotizing enterocolitis, or periventricular–intraventricular hemorrhage. In each group, 17 percent of the infants died by day 28. We conclude that treatment with the single-dose surfactant regimen used in this study reduces the severity of respiratory distress during the 72 hours after treatment and decreases the frequency of pneumothorax, but that it does not significantly improve clinical status later in the neonatal period and does not reduce neonatal mortality. Further study of different surfactant regimens and patient-selection criteria will be required to determine whether this initial improvement can be translated into reductions in mortality or serious morbidity. (N Engl J Med 1989; 320:959–65.) SINCE 1980, when Fujiwara and coworkers 1 first described improvements in oxygenation and ventilation after infants with established respiratory distress syndrome were treated with surfactant, the usefulness of exogenous surfactant from human or other animal sources to modify the course of respiratory disease in infants with respiratory distress syndrome or at risk for this syndrome has been confirmed in 13 randomized, controlled trials. 2 3 4 5 6 7 8 9 10 11 12 13 14 These trials have varied in terms of their patient-selection criteria, the surfactant preparations used, and the timing and dosage of surfactant administration. Despite the differences in study design, the intratracheal administration of surfactant resulted in improved blood gas . . .

Our film Dreams and Dilemmas: Parents and the Practice of Neonatal Care is on its way to meeting its goal of furthering the “Principles for Family Centered Neonatal Care” (Harrison H. Pediatrics 1993;92:643–50) through cinéma vérité depiction of parental involvement in decision-making. Reality-based filmmaking can provide valuable and successful educational material that advances care and understanding. However, there are real practical and ethical concerns such as privacy, consent, and uncertain or unknown future impact on participants. Successful reality-based filmmaking in a complex medical environment such as a neonatal intensive care unit requires careful attention to ways of ensuring full communication between all those involved and efforts to allay participants’ anxiety about being portrayed unfavorably. The most important ingredient, however, is the skill and ability of the filmmaker to engender trust.