Browsing by Author "Tooke, Lloyd"

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    A comparison of the accuracy of various methods of postnatal gestational age estimation; including Ballard score, foot length, vascularity of the anterior lens, last menstrual period and also a clinician's non-structured assessment
    (2020) Stevenson, Alexander Graham; Tooke, Lloyd; Joolay, Yaseen
    Rationale Gestational age is a strong determinant of neonatal mortality and morbidity. Early obstetric ultrasound is the clinical reference standard, but is not widely available in many developing countries. There is a well recognised need to identify reliable and simple methods of postnatal gestational age estimation. Methods A prospectively designed methods comparison study in a tertiary referral hospital in a developing country. Early ultrasound (<20 weeks) was the clinical reference standard. Methods evaluated included anthropometric measurements (including foot-length), vascularity of the anterior lens, the New Ballard Score and Last Menstrual Period. Clinicians' non-structured global impression “End of Bed” Assessment was also evaluated. Results 106 babies were included in the study. Median age at birth was 34 weeks (IQR 29-36). Ballard Score and “End of Bed” Assessment had a mean bias of -0.14 and 0.06 weeks respectively but wide 95% limits of agreement. The physical component of the Ballard score, the total Ballard score and Foot-length's ability to discriminate between term and preterm infants gave an AUROC of 0.97, 0.96 and 0.95 respectively. Discussion Although “End of Bed” Assessment and Ballard score had small mean biases, the wide confidence intervals render the methods irrelevant in clinical practice. Foot-length was particularly poor in Small for Gestational Age infants. None of the methods studied were superior to a non-structured clinician's informal “End of Bed” Assessment. Conclusion None of the methods studied met the a priori definition of clinical usefulness. Improving access to early ultrasound remains a priority. Instead of focusing on chronological accuracy, future research should compare the ability of early ultrasound and Ballard score to predict morbidity and mortality.
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    A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol
    (BioMed Central, 2023-09-19) Lategan, Ilse; Durand, David; Harrison, Michael; Nakwa, Firdose; Van Wyk, Lizelle; Velaphi, Sithembiso; Horn, Alan; Kali, Gugu; Soll, Roger; Ehret, Danielle; Zar, Heather; Tooke, Lloyd
    Introduction Respiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes. Methods and analysis The Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27–34+6 weeks’ gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25–0.35 in the first 2–24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05. Ethics and dissemination Ethical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004). Trial registration PACTR202307490670785
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    A two-year review of necrotising enterocolitis in very low birth weight infants (<1500g) in a South African tertiary hospital
    (2019) Gumede, Mbalenhle Purity; Tooke, Lloyd
    Background: There is paucity of local data on the profile of preterm very low birth weight (VLBW) infants who develop moderate to severe necrotising enterocolitis (NEC) and their outcomes. Methods: A retrospective folder review of VLBWs who developed Modified Bell’s stage II NEC or higher at Groote Schuur Hospital (GSH) nursery between January 2012 and December 2013 was performed. Outcomes were defined as requirement for surgery and mortality. Results: Forty seven infants were included (5% incidence). Gestational ages ranged from 25 to 36 weeks, 53% were 10 mg/L (60%) and subserosal gas radiologically (84%). Half the patients received mechanical ventilation, 38% required inotropes. The mortality rate was 64%. Three of the five infants that received surgery survived. Conclusion: Despite a similar incidence to global counterparts, our VLBW infants have severe NEC disease often requiring advanced life support, with a high mortality rate. HIV exposure may increase the risk of NEC development.
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    Antibiotic use in a level three NICU in South Africa
    (2018) Wireko, Brobby Naana; Tooke, Lloyd
    Background: Antibiotics are the most commonly used medications in the neonatal intensive care unit, and when used appropriately, can be lifesaving in the NICU. However, their inappropriate use has been found to be associated with certain adverse effects like Late Onset Sepsis, Necrotizing Enterocolitis, Chronic lung disease, Candidiasis, antibiotic resistance and death. Objective: This study seeks to describe the current antibiotic practices and management of neonatal sepsis including antibiotic use in a level III Neonatal unit in South Africa Method: The study was conducted at the Groote Schuur Hospital Neonatal Unit in South Africa which provides both emergency and continuous care for neonates in the Western Cape Province. All positive cultures as well as the duration of antibiotics within the period of 1st January 2016 to 31st December 2016 at the GSH Neonatal Unit were entered into a database. Data on infection and antibiotic use in Very Low Birth weight infants was extracted from the Vermont Oxford Network (VON) database. The GSH Neonatal Unit is one of the contributing units to the VON database. This was in addition to 2 Quality audits on antibiotic use in the unit done on 2 separate days in the months of February and November in 2016. The 10 month interval between the 2 audits was to allow for any policy changes to be implemented based on a series of educational webinars for staff that were organized during that period. Another audit was done in a randomly selected month collecting data of all infants on antibiotics for the entire month. Results: The overall incidence rates of Early and Late onset sepsis among the VLBW infants were 1.0% and 5.2% respectively with the 24 – 26 week Gestational age category having the highest rates. GBS and Klebsiella pneumonia were the leading pathogens for EOS and LOS respectively. The incidence of sepsis among babies bigger than 1500g was 0.52%.The commonly used antibiotics were Ampicillin, Gentamycin and Meropenem, which were consistent with the Unit‟s protocols. The major reasons for continued use of antibiotics beyond 48 hours were clinical signs concerning for risk of sepsis, pending culture results and laboratory results concerning for risk of sepsis. Regarding infants who received antibiotics for more than 48 hours, vii a comparison of both audits showed GSH plotting below the lower quartile at 30% in the 1st audit, and at 67% between the median and the lower quartile in the 2nd audit. Discussion: Gestational age has always been a universal risk factor for neonatal sepsis, and this was confirmed in this study. Inappropriate use of antibiotics in neonates arises on account of the difficulty clinicians face because of the nonspecific and vague nature of the signs of neonatal sepsis, especially in the VLBW category. Additional biomarkers for sepsis are increasingly being used to aid in the decision of whether or not to discontinue antibiotics after 36 - 48 hours. Conclusion: There is the need for stricter antibiotic stewardship to reduce the inappropriate use of antibiotics among neonates. Antibiotics being used at GSH are appropriate for the prevailing organisms although there are some resistant organisms.
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    Correlation between transcutaneous bilirubin and total serum bilirubin levels among preterm neonates at Groote Schuur Hospital
    (2012) Yaser, Abdallah; Rhoda, Natasha; Tooke, Lloyd
    Includes abstract. Includes bibliographical references.
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    HIV transmission to transmission to premature very low birth weight infants
    (2020) Levin, Candyce; Tooke, Lloyd
    There is sparse literature about HIV transmission in preterm infants. Eighty-two HIV-exposed preterm infants received birth polymerase chain reactions (PCRs). Five (6.1%) were HIV positive with all 5 mothers receiving inadequate antiretrovirals. Of the PCRnegative infants, 9 died and 87% of the survivors received further PCR testing which remained negative. With correct care, intrapartum transmission of HIV can virtually be eliminated.
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    Illness episodes in a cohort of preterm infants in their first year of life
    (2021) Muller, Seth; Tooke, Lloyd
    Background: There is limited data available regarding the illness episodes and hospital admissions of preterm infants after initial discharge in low- and middle-income countries. Objectives: To prospectively follow a cohort of HIV unexposed preterm infants (29-34 weeks) and describe their illness episodes, admissions and associated risk factors over a one-year period. Methods: The study was nested in a parent study evaluating the efficacy of a monoclonal antibody against RSV from Jan 2017 to March 2017. 53 infants were enrolled from two government neonatal nurseries in Cape Town, South Africa. Descriptive data were collected with regards to perinatal history and socioeconomic factors of the infants' household. All infants received careful follow-up. Logistic regression was performed to assess association between hospitalisation and socio-economic factors. Results: All 53 infants who were recruited were followed up over one year. There were 436 illness episodes of which 31 were hospital admissions. One infant died at home. The most common illnesses were respiratory (53%) and dermatological (17%) in nature. Lower respiratory tract infections accounted for 71% of all hospital admissions. There were no significant associations between socioeconomic subgroups when comparing illness episodes or hospital admissions. Conclusion: This is one of the few studies to record all illness episodes and not just admissions over a one-year period for HIV unexposed infants. There are high rates of intercurrent respiratory infection and hospitalisation of preterm infants in their first year of life. Public health interventions to reduce the risk of LRTI must be strengthened. Larger studies need to be done to be able to report on the associations with socioeconomic determinants in developing countries.
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    Invasive Group B Streptococcal disease in newborns at Groote Schuur Hospital
    (2023) Browne, Bradley; Tooke, Lloyd
    Background. Group B Streptococcal disease is an important cause of morbidity and mortality in newborns globally, and is more common in Sub-Saharan Africa and South Africa. There are few studies reporting on the burden of invasive Group B Streptococcus disease (iGBS) in newborns in South Africa, especially in the Western Cape. Objective. This study aims to describe a case series of newborns with iGBS in a tertiary hospital in the Western Cape. Methods. A retrospective folder review was conducted between January 2015 and December 2020. Results. Thirty five cases of invasive GBS disease were included in the study, 51% with earlyonset disease (EoD) and 49% with late-onset disease (LoD). The median gestational age at birth was 27 and 31.5 weeks in the LoD and EoD groups respectively. The median birth weight was 900 g and 1812 g in the LoD and EoD group respectively. Meningits was more common in the LoD group, and pneumonia more common in the EoD group. The overall mortality rate was 23%, and GBS disease accounted for a cumulative 274 days in the intensive care unit. Conclusion. Invasive GBS disease in newborns at GSH carries a high mortality rate with a similar burden of LoD and EoD. More studies of newborn iGBS are needed in the Western Cape and South Africa to better understand the burden of disease.
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    Morbidity and Mortality in small for gestational age very low birth weight infants in a middle-income country
    (2021) Mangiza, Marcia; Tooke, Lloyd; Rhoda, Natasha Raygaan
    Objective: To evaluate the impact of small for gestational age on outcomes of very low birth weight infants at Groote Schuur Hospital, Cape Town, South Africa. Study design: Data was obtained from Vermont Oxford Network Groote Schuur Hospital database from 2012 to 2018. Fenton growth charts were used to define small for gestational age as birth weight < 10th centile for gestational age. Results: Mortality (28.9% vs 18.5%, adjusted risk ratio (aRR) 2.1, 95% confidence interval (CI) 1.6-2.7), bronchopulmonary dysplasia (14% vs 4.5%, aRR 3.7, 95% CI 2.3-6.1) and late onset sepsis (16.7% vs 9.6%, aRR 2.3, 95% CI 1.6-3.3) were higher in the small for gestational age than in the non-small for gestational age group. Conclusion: Small for gestational age infants have a higher risk of mortality and morbidity among very low birth weight infants at Groote Schuur Hospital. This may be useful for counseling and perinatal management.
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    Short-term mortality and morbidity of very-low birth weight infants over 9 years at Groote Schuur Hospital
    (2025) Dumaresq, Helen; Tooke, Lloyd
    Background: With the advancement of neonatal care there has been a decrease in mortality rates of VLBW infants worldwide. However, this has been at the cost of increased morbidity in this vulnerable group. Currently there are little up to date data on short term morbidities for VLBW infants in low and middle-income countries. Objectives: The primary objective was to describe the neonatal mortality rate in infants 401g-1500g admitted to Groote Schuur neonatal nursery over 9 years and within weight categories. Secondary objectives were to evaluate the main neonatal short-term morbidities of these infants over time and within weight categories. Methods: This study is a secondary analysis of prospectively collected observational data. All VLBW (<1501g) infants admitted to Groote Schuur Neonatal unit from 2012-2020 were included in the study. Data were benchmarked against the Vermont Oxford Network database. Results: Of the 4644 infants included in the study the overall mortality rate was 19.8%, which remained static over the study period and was higher in comparison to the VON. There was a significantly higher mortality rate associated with decreasing birth weight. The mortality rate for outborn vs inborn infants was higher: 30.3% vs 18.4% (p value 0.046). There was a significant risk of short-term morbidity in infants <1001g vs 1001- 1500g. The survival rate without major morbidity was 65.8% overall. There was a higher survival rate without morbidities with increasing birth weight. Survival rates without morbidity were comparable to that of the VON. Conclusion: The results demonstrate that mortality rates are higher in comparison to developed countries. However, importantly, survival without morbidity is comparable. Strategies to improve mortality and morbidity in VLBW infants are multifaceted and require a collaborative and innovative approach. Important strategies include an emphasis on improved antenatal care, regionalization of care, screening facilities, neonatal specific training of staff, antenatal steroids, CPAP, surfactant replacement therapy, stringent infection control procedures, kangaroo mother care and promotion of breastfeeding.
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    Short-term mortality and morbidity of very-low birth weight infants over 9 years at Groote Schuur Hospital
    (2025) Dumaresq, Helen; Tooke, Lloyd
    Background: With the advancement of neonatal care there has been a decrease in mortality rates of VLBW infants worldwide. However, this has been at the cost of increased morbidity in this vulnerable group. Currently there are little up to date data on short term morbidities for VLBW infants in low and middle-income countries. Objectives: The primary objective was to describe the neonatal mortality rate in infants 401g-1500g admitted to Groote Schuur neonatal nursery over 9 years and within weight categories. Secondary objectives were to evaluate the main neonatal short-term morbidities of these infants over time and within weight categories. Methods: This study is a secondary analysis of prospectively collected observational data. All VLBW (<1501g) infants admitted to Groote Schuur Neonatal unit from 2012-2020 were included in the study. Data were benchmarked against the Vermont Oxford Network database. Results: Of the 4644 infants included in the study the overall mortality rate was 19.8%, which remained static over the study period and was higher in comparison to the VON. There was a significantly higher mortality rate associated with decreasing birth weight. The mortality rate for outborn vs inborn infants was higher: 30.3% vs 18.4% (p value 0.046). There was a significant risk of short-term morbidity in infants <1001g vs 1001- 1500g. The survival rate without major morbidity was 65.8% overall. There was a higher survival rate without morbidities with increasing birth weight. Survival rates without morbidity were comparable to that of the VON. Conclusion: The results demonstrate that mortality rates are higher in comparison to developed countries. However, importantly, survival without morbidity is comparable. Strategies to improve mortality and morbidity in VLBW infants are multifaceted and require a collaborative and innovative approach. Important strategies include an emphasis on improved antenatal care, regionalization of care, screening facilities, neonatal specific training of staff, antenatal steroids, CPAP, surfactant replacement therapy, stringent infection control procedures, kangaroo mother care and promotion of breastfeeding.
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    The short-term outcomes of HIV-exposed versus HIV-unexposed very low birth weight infants
    (2017) Riemer, Linda Jane; Tooke, Lloyd
    Introduction: HIV exposed but uninfected infants have been shown to have a higher morbidity and mortality than unexposed infants. There is almost no literature comparing the short-term outcomes of HIV exposed versus unexposed VLBW neonates who are born prematurely. Methods: A retrospective review of all VLBW neonates who were admitted at Groote Schuur Hospital nursery from 2012-2014. Data were obtained from the Vermont Oxford Database and the Prevention of Mother to Child register. Results: A total of 1593 VLBW neonates were admitted during the 3 years of which it was possible to obtain maternal HIV status in 1579 babies. Of these 1579 babies, 316 (20%)were HIV exposed. Eleven of the 230 (4.8%)infant HIV tests were positive. There was no difference in mortality, birth weight, gestational age, length of stay, sepsis and delivery room outcomes for the HIV-exposed (HIVE), maternal ARV-exposed (mARVE) and HIV-positive neonates. Differences between HIV exposed and HIV unexposed neonates were noted in an increased risk of NEC [OR 1.83 (1.2-2.8)] and an increased need for ventilation [OR 1.35 (1.01-1.8)]. Maternal antiretroviral exposed neonates developed less NEC compared with maternal antiretroviral under-exposed neonates with a birth weight under 1000grams appearing to contribute in the development and outcome of NEC. Differences in HIV-positive neonates included more chronic lung disease [OR 5.49 (1.31-23)] and more necrotising enterocolitis [OR 4.12 (1.02-17.18)]. Conclusion: This study is the first to compare the short-term outcomes of HIV exposed and HIV unexposed very low birth weight infants and consider maternal ARV exposure. It demonstrated no difference in birth weight, gestational age, mortality or sepsis. Necrotising enterocolitis is increased in the HIV exposed neonates especially if they are under-exposed to maternal antiretrovirals. Adequate maternal antiretrovirals may have a protective effect on incidence of necrotising enterocolitis and respiratory outcomes.
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    Symptomatic congenital syphilis in a tertiary neonatal unit: a retrospective descriptive study
    (2016) Pillay, Shakti; Tooke, Lloyd
    Background: Syphilis is a disease that was first described in the 1300s and now 700 years later, despite preventive measures and effective treatment, continues to impact on a global scale, with the burden falling largely on the developing world. We could find no recent published literature looking at predictors of outcomes in neonates born with symptomatic congenital syphilis, especially in the context of a tertiary neonatal setting. Methodology: The study design was a retrospective descriptive folder review of neonates born with symptomatic congenital syphilis at Groote Schuur Hospital (GSH) from January 2011 to December 2013. One of the primary objectives was to address outcome as well as look at modifiable preventable factors. All neonates treated at GSH (inborn and outborn) who tested serologically positive for syphilis together with clinical signs of syphilis were included. Data was obtained from the National Health Laboratory System (NHLS) database, as well as the notification and death registers at GSH nursery. All data was collected in a Microsoft excel spread sheet and analysed using Microsoft StatPlus. Results: Fifty of eighty neonates (62.5%) with positive syphilis serology as well as clinical signs of congenital syphilis were included together with their fifty mothers. The majority (98%) of mothers were inadequately untreated. Nineteen neonates demised. There were no statistically significant differences between the deaths and survivors in terms of gestational age (p = 0.15), birth weight (p = 0.08) or maternal age (p = 0.51). Two significant predictors of mortality were one minute and five minute Apgar scores of less than five ([RR], 3.5; 95% CI 1.6-7.7 and [RR], 2.9; 95% CI 1.5-5.3 respectively). Hydropic neonates, tended to be sicker at birth, requiring intubation and inotropes, which was associated with a poorer outcome (increased risk of mortality). Conclusion: Despite the introduction of a National Syphilis Screening programme more than twenty years ago together with a large proportion of pregnant women having access to antenatal care, congenital syphilis is still prevalent in South Africa. Failure to access antenatal care, poor partner tracing and a number of modifiable health worker related failures contribute to poor maternal diagnosis and treatment. Many neonates with congenital syphilis require aggressive interventions and there is a high mortality rate. This dissertation adds to the existing body of research particularly with regard to predictors of outcome in tertiary neonatal settings. Certain categories of neonates have a lower survival rate and guidelines about limitation of care may need to be considered in order to optimise resource allocation particularly in resource-constrained settings. Further research is required to elaborate how best to develop protocols in these neonates.
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    The introduction of multi-strain probiotics to preterm infants in a regional hospital: an observational study
    (2025) Abrahams, Meliza; Tooke, Lloyd
    Background: Worldwide 1 in 10 of all infants are born preterm. Late onset sepsis (LOS) (>3days of life) and necrotising enterocolitis (NEC) are important causes of morbidity and mortality in this vulnerable group. Probiotics may help to decrease the incidence of these conditions, although controversies remain. Objectives: To describe the implementation of multi-strain probiotics in George Hospital (GH) and determine the incidence of NEC, LOS and mortality in this group. Also, to compare with previous years where there were either no probiotics or only single strain probiotics. Methods: A retrospective observational study was conducted between February 2019 to July 2020 at George Hospital, Western-Cape, South-Africa. Data were collected from infants who weighed between 800g to 1200g to observe the occurrence of LOS and NEC. Results: Seventy-seven inborn infants were included. They had a median weight of 1000g, IQR [900- 1120g] and a median gestation of 30weeks, IQR [28-31weeks]. The ratio of male to female was 51:49. All of them received breastmilk. A total of eleven (14.3%) infants had positive cultures. These were predominantly gram-negative organisms and there were no positive cultures of probiotic organisms. Seventy five percent of the infections occurred in ELBW infants and their risk for mortality is higher overall. There was a total of seven deaths (9%) of which 3 were before 72hours of life. Out of all the 77 infants 4 died of LOS. None of the infants in the group had clinical or radiological NEC. Compared with the previous time periods, there was a similar rate of LOS, but a reduction of NEC and death. Conclusion: The introduction of probiotics to a regional hospital is possible. Less NEC was observed during the administration of multi-strain probiotics
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    The use of inhaled nitric oxide to treat persistent pulmonary hypertension of the newborn in a tertiary public hospital in South Africa from 2010-2014: morbidity, mortality and cost
    (2018) McAlpine, Alastair; Horn, Alan R; Tooke, Lloyd
    Background and rationale: Inhaled nitric oxide (iNO) is recommended for the treatment of severe persistent pulmonary hypertension of the newborn (PPHN) because it reduces the need for extracorporeal membrane oxygenation (ECMO). There is insufficient evidence that iNO reduces mortality in the absence of ECMO. Although neonates in some South African public hospitals have access to iNO, ECMO is not available. Oral sildenafil can be effective in settings where iNO is not available, but its effect on outcome and cost of treatment in this setting have not been described. The literature review in the first part of this thesis describes five studies reporting short-term outcomes of PPHN in the absence of ECMO. No studies from South Africa were identified. Only two studies described outcomes after iNO – the coadministration of Sildenafil with iNO was only reported in one small study. There were insufficient published data to guide management in settings where ECMO is not available. Aim: To describe a cohort of term and near term neonates with PPHN who were treated with iNO, with or without sildenafil, in a tertiary neonatal unit in South Africa Objectives: (i) to describe the characteristics at birth, the clinical course, and shortterm outcomes; (ii) to determine if any variables were associated with mortality; (iii) to describe the relationship between the use of sildenafil and cost of care, represented by the duration of intubation and iNO use; and (iv) to describe the frequency of sildenafil prescription. Methods. A retrospective review was carried out on folders of neonates with PPHN who were treated with iNO in Groote Schuur Hospital, Cape Town, South Africa, between January 2010 and December 2014. Results. Forty neonates were included – most were full term (85%). Meconium aspiration syndrome (MAS) was the commonest cause of PPHN (50%), followed by intrapartum hypoxia (20%), sepsis (17.5%), pulmonary hypoplasia (7.5%) and idiopathic (5%). Fourteen neonates (35%) died. Pulmonary hypoplasia and pneumothorax were associated with mortality (p=0.037 and p=0.004 respectively). An FiO2 of 1.0 and an iNO dose of ≥ 20 ppm at 24 and 48 hours respectively, both predicted death (specificity 89% vs. 100%, sensitivity 67% vs. 43% and p=0.003 vs. p=0.007 respectively). Sildenafil was prescribed more often after 2011 (83% vs. 65%) and was associated with increased survival (p=0.018) – early administration was associated with a shorter time to extubation (p=0.012) and a shorter course of iNO (p=0.044). Conclusion. The treatment of PPHN with iNO in the absence of ECMO was associated with high mortality, particularly in neonates with congenital lung abnormalities. The FiO2 and iNO requirements at 24 and 48 hours respectively could be used to identify neonates who are unlikely to benefit from continued treatment. Sildenafil was prescribed with increasing frequency during the study. The combination of iNO with sildenafil was associated with more cost-effective care and improved short term outcomes. These findings provide a potential basis for costsaving measures and resource allocation.