RESUMO
Prenatal exome sequencing (pES) is a promising tool for diagnosing genetic disorders when structural anomalies are detected on prenatal ultrasound. The aim of this study was to investigate the diagnostic yield and clinical impact of pES as an additional modality for fetal neurologists who counsel parents in case of congenital anomalies of the central nervous system (CNS). We assessed 20 pregnancies of 19 couples who were consecutively referred to the fetal neurologist for CNS anomalies. pES had a diagnostic yield of 53% (10/19) with most diagnosed pregnancies having agenesis or hypoplasia of the corpus callosum (7/10). Overall clinical impact was 63% (12/19), of which the pES result aided parental decision making in 55% of cases (6/11), guided perinatal management in 75% of cases (3/4), and was helpful in approving a late termination of pregnancy request in 75% of cases (3/4). Our data suggest that pES had a high diagnostic yield when CNS anomalies are present, although this study is limited by its small sample size. Moreover, pES had substantial clinical impact, which warrants implementation of pES in the routine care of the fetal neurologist in close collaboration with gynecologists and clinical geneticists.
Assuntos
Sequenciamento do Exoma , Feto/anormalidades , Malformações do Sistema Nervoso/diagnóstico , Malformações do Sistema Nervoso/genética , Diagnóstico Pré-Natal/métodos , Tomada de Decisão Clínica , Consanguinidade , Gerenciamento Clínico , Feminino , Feto/diagnóstico por imagem , Estudos de Associação Genética , Predisposição Genética para Doença , Humanos , Malformações do Sistema Nervoso/terapia , Neurologistas , Gravidez , Resultado da Gravidez , Ultrassonografia Pré-Natal , Sequenciamento do Exoma/métodosRESUMO
Nosocomial bloodstream infections (NBSIs), commonly due to central-line associated bloodstream infections (CLABSI), contribute substantially to neonatal morbidity and mortality. We aimed to identify longitudinal changes in incidence of NBSI, microbiological-spectrum, and antibiotic exposure in a large cohort of preterm neonates admitted to the neonatal intensive care unit. We retrospectively assessed differences in annual rates of NBSI (per 1000 patient-days), CLABSI (per 1000 central-line days), and antibiotic consumption (per 1000 patient-days) among preterm neonates (< 32 weeks' gestation) hospitalized between January 2012 and December 2020. Multi-state Markov models were created to model states of progression of NBSI and infection risk given a central-line on days 0, 3, 7, and 10 of admission. Of 1547 preterm infants, 292 (19%) neonates acquired 310 NBSI episodes, 99 (32%) of which were attributed to a central-line. Over the years, a significant reduction in central-line use was observed (p < 0.001), although median dwell-time increased (p = 0.002). CLABSI incidence varied from 8.83 to 25.3 per 1000 central-line days, with no significant difference between years (p = 0.27). Coagulase-negative staphylococci accounted for 66% of infections. A significant decrease was found in antibiotic consumption (p < 0.001). Probability of NBSI decreased from 16% on day 3 to 6% on day 10. NBSI remains a common problem in preterm neonates. Overall antibiotic consumption decreased over time despite the absence of a significant reduction in infection rates. Further research aimed at reducing NBSI, in particular CLABSI, is warranted, particularly with regard to limiting central-line dwell-time and fine-tuning insertion and maintenance practices.
Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Infecção Hospitalar , Sepse , Antibacterianos/uso terapêutico , Infecções Relacionadas a Cateter/epidemiologia , Coagulase , Infecção Hospitalar/microbiologia , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Estudos Retrospectivos , Sepse/epidemiologiaRESUMO
OBJECTIVES: Sepsis is a common cause of maternal mortality and morbidity. Early detection and rapid management are essential. In this study, we evaluate the compliance with the implemented maternity-specific Early Warning Score (EWS), Rapid Response Team (RRT) protocol and the Surviving Sepsis Campaign (SSC) Hour-1 Bundle in a tertiary hospital in the Netherlands. METHODS: We performed a retrospective patient chart review from July 2019 to June 2020 at the Leiden University Medical Centre. We included women who received therapeutic antibiotics and were admitted for at least 24 hours. RESULTS: We included 240 women: ten were admitted twice and one woman three times, comprising 252 admissions. A clinical diagnosis of sepsis was made in 22 women. The EWS was used in 29% (n = 73/252) of admissions. Recommendations on the follow-up of the EWS were carried out in 53% (n = 46/87). Compliance with the RRT protocol was highest for assessment by a medical doctor within 30 minutes (n = 98/117, 84%) and lowest for RRT involvement (n = 7/23, 30%). In women with sepsis, compliance with the SSC Bundle was highest for acquiring blood cultures (n = 19/22, 85%), while only 64% (n = 14/22) received antibiotics within 60 minutes of the sepsis diagnosis. CONCLUSION: The adherence to the maternity-specific EWS and the SSC Hour-1 bundle was insufficient, even within this tertiary setting in a high-income country.
Assuntos
Fidelidade a Diretrizes , Sepse , Centros de Atenção Terciária , Humanos , Feminino , Países Baixos , Centros de Atenção Terciária/organização & administração , Estudos Retrospectivos , Sepse/terapia , Sepse/diagnóstico , Fidelidade a Diretrizes/estatística & dados numéricos , Adulto , Gravidez , Antibacterianos/uso terapêutico , Escore de Alerta Precoce , Guias de Prática Clínica como Assunto , Complicações Infecciosas na Gravidez/tratamento farmacológico , Complicações Infecciosas na Gravidez/terapia , Complicações Infecciosas na Gravidez/diagnósticoRESUMO
OBJECTIVE: To test the effect of 800 µg of misoprostol orally on the prevention of manual removal of retained placenta. DESIGN: Multicenter, double-blinded, placebo-controlled, randomized trial. SETTING: One university and one non-university teaching hospital in the Netherlands. SAMPLE: 99 women with retained placenta (longer than 60 min after childbirth) in the absence of postpartum hemorrhage. METHODS: Eligible women were administered either 800 µg of misoprostol or placebo orally. MAIN OUTCOME MEASURES: Number of manual removals of retained placenta and amount of blood loss. RESULTS: Manual removal of retained placenta was performed in 50% of the women who received misoprostol and in 55% who received placebo (relative risk 0.91, 95% confidence interval 0.62-1.34). No difference in the amount of blood loss (970 vs. 1120 mL; p = 0.34) was observed between the two groups. CONCLUSIONS: Administration of 800 µg of oral misoprostol, one hour after childbirth, does not seem to reduce the number of manual removals of retained placentas. The time elapsing results in the delivery of 50% of the retained placentas at the expense of an increased risk of postpartum hemorrhage.
Assuntos
Misoprostol/administração & dosagem , Ocitócicos/administração & dosagem , Placenta Retida/tratamento farmacológico , Cuidado Pós-Natal/métodos , Hemorragia Pós-Parto/prevenção & controle , Administração Oral , Método Duplo-Cego , Feminino , Humanos , Países Baixos , Placenta Retida/terapia , Gravidez , Transtornos Puerperais/prevenção & controle , Resultado do TratamentoRESUMO
OBJECTIVE: The International Consortium for Health Outcomes Measurement developed the Pregnancy and Childbirth (PCB) outcome set to improve value-based perinatal care. This set contains clinician-reported outcomes and patient-reported outcomes. We validated the set for use in the Netherlands by exploring its applicability among all end-users prior to implementation. METHODS: A mixed-methods design was applied. A survey was performed to assess patients (nâ¯=â¯142), professionals (nâ¯=â¯134) and administrators (nâ¯=â¯35) views on the PCB set. To further explore applicability, separate focus groups were held with representatives of each of these groups. RESULTS: The majority of survey participants agreed that the PCB set contains the most important outcomes. Patient-reported experience measures were considered relevant by the majority of participants. Perceived relevance of patient-reported outcome measures varied. Main themes from the focus groups were content of the set, data collection timing, implementation (also IT and transparency), and quality-based governance. CONCLUSION: This study supports suitability of the PCB outcome set for implementation, evaluation of quality of care and shared decision making in perinatal care. PRACTICE IMPLICATIONS: Implementation of the PCB set may change existing care pathways of perinatal care. Focus on transparency of outcomes is required in order to achieve quality-based governance with proper IT solutions.