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On October 27, 1991, the Turkmen Soviet Socialist Republic declared its independence from the Soviet Union. Hammer and sickle gave way to a flag, a national anthem, and new holidays. Seven decades earlier, Turkmenistan had been a stateless conglomeration of tribes. What brought about this remarkable transformation? Tribal Nationaddresses this question by examining the Soviet effort in the 1920s and 1930s to create a modern, socialist nation in the Central Asian Republic of Turkmenistan. Adrienne Edgar argues that the recent focus on the Soviet state as a \"maker of nations\" overlooks another vital factor in Turkmen nationhood: the complex interaction between Soviet policies and indigenous notions of identity. In particular, the genealogical ideas that defined premodern Turkmen identity were reshaped by Soviet territorial and linguistic ideas of nationhood. The Soviet desire to construct socialist modernity in Turkmenistan conflicted with Moscow's policy of promoting nationhood, since many Turkmen viewed their \"backward customs\" as central to Turkmen identity. Tribal Nationis the first book in any Western language on Soviet Turkmenistan, the first to use both archival and indigenous-language sources to analyze Soviet nation-making in Central Asia, and among the few works to examine the Soviet multinational state from a non-Russian perspective. By investigating Soviet nation-making in one of the most poorly understood regions of the Soviet Union, it also sheds light on broader questions about nationalism and colonialism in the twentieth century.

ObjectivePrevious studies examine clinical outcomes of insulin therapy in neonatal intensive care units (NICUs), without first developing safe and effective control protocols. This research quantifies the safety and performance of a computerised model-based control algorithmSTAR-GRYPHON (Stochastic TARgeted Glucose Regulation sYstem to Prevent Hyper- and hypO-glycaemia in Neonates).DesignRetrospective observational study of glycaemic control in very/extremely low birthweight infants treated with insulin from Christchurch Women’s Hospital NICU between January 2013 and June 2017. Blood glucose (BG) outcomes and control performance is compared with retrospective data (n=22) and literature.InterventionsInsulin infusion doses were calculated from 3 to 4 hourly BG measurements using a computerised model-based control algorithm, STAR-GRYPHON.Main outcome measuresMean BG, time in targeted range and incidence of hypoglycaemia.ResultsSTAR-GRYPHON (n=35) had lower mean BG concentration (7.0mmol/L vs 7.9 mmol/L), higher %BG within the 4.0–8.0 mmol/L target range (71.1% vs 50.9%) and lower %BG <4.0 mmol/L (0.6% vs 2.1%). There were only 2 BG <2.6 mmol/L (over n=2, 5.5% of patients, 0.03% of all BG outcomes), one of which may be attributed to clinical error. These results show better control to target and lower incidence of hypoglycaemia than most literature results from intensive insulin therapy protocols or study groups in children and infants.ConclusionsModel-based protocols can safely and effectively control BG in very premature infants and should be used in future studies to determine the effect of insulin therapy on clinical outcomes.

Background Hyperglycemia often occurs in premature, very low birthweight infants (VLBW) due to immaturity of endogenous regulatory systems and the stress of their condition. Hyperglycemia in neonates has been linked to increased morbidities and mortality and occurs at increasing rates with decreasing birthweight. In this cohort, the emerging use of insulin to manage hyperglycemia has carried a significant risk of hypoglycemia. The efficacy of blood glucose control using a computer metabolic system model to determine insulin infusion rates was assessed in very-low-birth-weight infants. Methods Initial short-term 24-hour trials were performed on 8 VLBW infants with hyperglycemia followed by long-term trials of several days performed on 22 infants. Median birthweight was 745 g and 760 g for short-term and long-term trial infants, and median gestational age at birth was 25.6 and 25.4 weeks respectively. Blood glucose control is compared to 21 retrospective patients from the same unit who received insulin infusions determined by sliding scales and clinician intuition. This study was approved by the Upper South A Regional Ethics Committee, New Zealand (ClinicalTrials.gov registration NCT01419873). Results Reduction in hyperglycemia towards the target glucose band was achieved safely in all cases during the short-term trials with no hypoglycemic episodes. Lower median blood glucose concentration was achieved during clinical implementation at 6.6 mmol/L (IQR: 5.5 – 8.2 mmol/L, 1,003 measurements), compared to 8.0 mmol/L achieved in similar infants previously (p < 0.01). No significant difference in incidence of hypoglycemia during long-term trials was observed (0.25% vs 0.25%, p = 0.51). Percentage of blood glucose within the 4.0 – 8.0 mmol/L range was increased by 41% compared to the retrospective cohort (68.4% vs 48.4%, p < 0.01). Conclusions A computer model that accurately captures the dynamics of neonatal metabolism can provide safe and effective blood glucose control without increasing hypoglycemia. Trial Registration ClinicalTrials.gov registration NCT01419873

ObjectivesTo compare necrotising enterocolitis (NEC) prevention practices and NEC associated factors between units from eight countries of the International Network for Evaluation of Outcomes of Neonates, and to assess their association with surgical NEC rates.DesignProspective unit-level survey combined with retrospective cohort study.SettingNeonatal intensive care units in Australia/New Zealand, Canada, Finland, Israel, Spain, Sweden, Switzerland and Tuscany (Italy).PatientsExtremely preterm infants born between 240 to 286 weeks’ gestation, with birth weights<1500 g, and admitted between 2014–2015.ExposuresNEC prevention practices (probiotics, feeding, donor milk) using responses of an on-line pre-piloted questionnaire containing 10 questions and factors associated with NEC in literature (antenatal steroids, c-section, indomethacin treated patent ductus arteriosus and sepsis) using cohort data.Outcome measuresSurgical NEC rates and death following NEC using cohort data.ResultsThe survey response rate was 91% (153 units). Both probiotic provision and donor milk availability varied between 0%–100% among networks whereas feeding initiation and advancement rates were similar in most networks. The 9792 infants included in the cohort study to link survey results and cohort outcomes, revealed similar baseline characteristics but considerable differences in factors associated with NEC between networks. 397 (4.1%) neonates underwent NEC surgery, ranging from 2.4%–8.4% between networks. Standardised ratios for surgical NEC were lower for Australia/New Zealand, higher for Spain, and comparable for the remaining six networks.ConclusionsThe variation in implementation of NEC prevention practices and in factors associated with NEC in literature could not be associated with the variation in surgical NEC incidence. This corroborates the current lack of consensus surrounding the use of preventive strategies for NEC and emphasises the need for research.

Introduction Hypoproteinaemia leads to spuriously high-sodium values when measured by indirect ion-selective electrodes (ISE) as used in main laboratory analysers compared with direct ISE employed in point-of-care analysers (POCT). The authors, therefore, investigated the occurrence of hypoalbuminaemia and its effect on measured sodium from POCT and the main laboratory analyser of neonatal intensive-care samples. Method Sodium, in paired retrospective samples, measured by the main laboratory and neonatal unit blood-gas (POCT) analysers were compared. Results Hypoalbuminaemia (<30 g/l) was present in 1400/2420 paired results. Sodium was higher when measured by laboratory analyser, the difference increased with decreasing albumin; sodium (laboratory – POCT)=7.6 (±1.1)–0.22 (±0.04)×albumin. A difference >3 mmol/l was present in 31% and consequently underestimated (9.4%) hyponatraemia and overestimated (3.8%) hypernatraemia. Conclusion Hypoalbuminaemia is common in sick neonates and monitoring electrolytes using POCT and laboratory analysers frequently yield significantly different results with consequent misclassification. In these patients, measurement of electrolytes by direct ISE (blood-gas analyser) may be more accurate.

Background: Aminoglycoside-induced ototoxicity has been reported in neonates but its incidence is poorly defined, whereas vancomycin-induced ototoxicity has not been reported in neonates. Objective: To compare hearing test results in infants in a neonatal intensive care unit (NICU) who were or were not treated with extended interval gentamicin dosing and/or standard vancomycin dosing. Method:A database of otoacoustic emissions (OAE), over a 5-year period of NICU admissions, was combined with databases of gentamicin and vancomycin dosing to compare patients treated or not treated with these antibiotics.Results:A total of 2,347 OAE results was available. OAE failure rates were: no gentamicin and no vancomycin (noGnoV), 7% (85/1,233); gentamicin but no vancomycin (GnoV), 4% (42/949); vancomycin but no gentamicin (VnoG), 22% (9/41) and gentamicin and vancomycin (GandV), 14% (17/124). Compared to noGnoV there was a decreased risk of OAE failure in GnoV (p = 0.022, OR 0.64, 95% CI 0.44–0.94) and an increased risk in VnoG (p = 0.003, OR 3.46, 95% CI 1.54–7.75) and GandV, (p = 0.006, OR 2.20, 95% CI 1.26–3.83). Conclusions:Gentamicin, as used and evaluated in this audit, showed no evidence of an increased risk of ototoxicity; what was observed was a statistically significant decrease in OAE failure rate. Vancomycin, by contrast, was associated with ototoxicity.

ObjectiveTo describe the trend and risk factors for severe intraventricular haemorrhage (IVH) among infants <32 weeks gestation.DesignPopulation-based cohort study.SettingAustralia and New Zealand.PatientsAll preterm infants <32 weeks gestation in the Australian and New Zealand Neonatal Network (ANZNN) from 1995 to 2012.InterventionsComparison of IVH incidence between 6-year epochs.Main outcome measuresOverall IVH and severe IVH incidence.ResultsA total of 60 068 infants were included, and overall survival to discharge increased from 89% to 93% over the three epochs. As the percentage of infants with IVH decreased from 23.6% to 21.3% and 21.4% (p<0.001) from epoch 1 to 3, respectively, fewer survivors had severe IVH (4.0%, 3.3% and 2.8%, respectively, p<0.001). Over time, there were fewer antenatal complications, higher antenatal steroid usage and more caesarean-section births. Fewer infants were intubated at birth, had low 5 min Apgar score, had sepsis or pneumothorax needing drainage. Adjusted for perinatal confounders, there was significant reduction in odds of severe IVH from epoch 1 to 3 (adjusted OR (AOR) 0.8, 95% CI 0.7 to 0.9). Factors associated with development of severe IVH include no antenatal steroids (AOR 1.7, 95% CI 1.5 to 1.9), male (AOR 1.3, 95% CI 1.2 to 1.4), 5 min Apgar score <7 (AOR 2.0, 95% CI 1.9 to 2.2), intubated at birth (AOR 2.0, 95% CI 1.8 to 2.2), extremely low gestational age (AOR 4.0, 95% CI 3.7 to 4.4), outborn (AOR 1.6, 95% CI 1.5 to 1.8) and vaginal delivery (AOR 1.4, 95% CI 1.3 to 1.6).ConclusionsAlong with increased survival among infants born <32 weeks gestation, the incidence of severe IVH has decreased over the 18 years, especially in the most recent period. This coincided with reduction in rates of risk factors for severe IVH development.

Background Faltering postnatal growth in preterm babies is associated with adverse neurodevelopment. However, which growth reference is most helpful for predicting neurodevelopment is unknown. We examined associations between faltering growth and developmental delay in extremely low birthweight (ELBW) infants. Methods We categorized faltering growth (z-score decrease ≥0.8 for weight/length, >1 for head circumference) between birth, 4 weeks, 36 weeks’ postmenstrual age and 2 years’ corrected age using fetal (Fenton, UK-WHO and Olsen) and healthy preterm (INTERGROWTH-21st) references. Associations between faltering growth and developmental delay were examined using binary logistic regression and area under the receiver operating curve (AUC). Results In 327 infants, Olsen charts identified the highest prevalence of faltering growth (weight 37%, length 63%, head 45%). Agreement in classification was higher amongst fetal references (kappa coefficient, ĸ  = 0.46–0.94) than between INTERGROWTH-21st and fetal references ( ĸ  = 0.10–0.81). Faltering growth in all measures between 4–36 weeks (odds ratio, OR 2.0–4.7) compared with other time intervals (OR 1.7–2.7) were more strongly associated with developmental delay, particularly motor delay (OR 2.0–4.7). All growth references were poorly predictive of developmental delay at 2 years (AUC ≤ 0.62). Conclusions Faltering postnatal growth in ELBW infants is associated with, but is poorly predictive of, developmental delay at 2 years. Impact In babies born preterm, different growth references result in wide variation in categorization of faltering postnatal growth. Faltering growth in weight, length, and head circumference from 4 weeks to 36 weeks’ postmenstrual age are associated with developmental delay at 2 years’ corrected age, particularly motor delay. However, postnatal growth is a poor predictor of later developmental delay in extremely low birthweight infants irrespective of the growth reference used.

Pleistocene paleodune deposits occur along the Oregon coast, underlying coastal towns, roadways, and associated power and water infrastructure(s). Secondary cementation within these deposits provides some stability, allowing for near-vertical sea cliffs and roadcut outcrops. Yet, slope instability is a prevalent hazard observed within the paleodune deposits. Weakening of cementing agents via changes to groundwater conditions due to altered vegetation, climate change, or contamination, for example, could promote slope instability, threatening lives and infrastructure. This study aims to investigate the variability in the type and degree of cementation and to determine how they are affected by changes in groundwater conditions.To assess relationships between stratigraphy, soil moisture, and the type and degree of cementation fifty-six soil samples from four profiles within the Newport paleodune sheet were analyzed for bulk properties (grain size, density, porosity, and moisture content), mineralogy, and cement characteristics via X-ray diffraction, scanning electron microscopy, and optical microscopy. To determine the chemistry of waters associated with these deposits thirty groundwater samples and seven porewater samples were analyzed via ion chromatography, inductively coupled plasma mass spectrometry, and isotope analysis. Results of these analyses were used in geochemical modeling using PhreeqC and Geochemist’s Workbench to better understand how cementing agents may be affected by changing groundwater conditions and chemistries.Stratigraphic profiles and penetrometer measurements confirm these deposits are variably cemented, and reveal more weakly cemented zones are primarily associated with permeability boundaries along loess-paleosols, accumulations of Fe- and Mn-rich laminae, or the underlying bedrock. Results of mineralogical analyses reveal cementing agents consist of hydrated minerals including Al-phases such as gibbsite, allophane, vermiculite, and halloysite, which typically form a discontinuous coating on the sand grains, and Fephases such as goethite, ferrihydrite, and Fe-/Mn-oxides, which typically completely fill pores between sand grains and provide exceptional cohesion. Results of groundwater analyses and modeling reveal the Fe- and Mn-rich cementing agents are mobilized by fluctuating groundwater flow, particularly under low redox conditions characteristic of deeper flow systems, while the Al-rich cementing agents are relatively immobile, particularly under higher pH conditions, although the range of favorable pH is narrow. Furthermore, waters associated with the deposits are generally poorly buffered, and thus are susceptible to significant changes in pH. This study provides a more thorough understanding of the type and degree of cementing agents, their relationship with groundwater and stratigraphy, and the soil formation processes involved. The results can be used as a framework to evaluate the potential hazard posed by the variably cemented paleodune deposits, particularly slope stability given site-specific characteristics. Additionally, this framework can guide planners and regulators overseeing coastal development in assessing how anthropogenic impacts, including climate change, could potentially impact the stability of the paleodune deposits.