Exploring Infant Feeding Experiences and Maternity Care Practices in Appalachia.

OBJECTIVES: Our aim was to explore postpartum individuals' experiences and perceptions of breastfeeding and International Board Certified Lactation Consultants' (IBCLC) knowledge and perceptions of maternity care practices and perceived barriers to breastfeeding among their patient populations in Appalachia. METHODS: Semistructured interviews were conducted with seven IBCLCs and seven postpartum individuals. Interviews were recorded and transcribed. Thematic analysis was conducted to determine emergent themes and subthemes related to knowledge/perceptions, experiences, and barriers to breastfeeding among postpartum individuals, as well as emergent themes associated with the knowledge and perceptions of maternity care practices, easy-/difficult-to-implement Baby-Friendly Hospital Initiative maternity care practices, and perceived barriers to breastfeeding among IBCLCs. RESULTS: Postpartum individuals recruited from an Appalachian obstetrics/gynecology clinic were aware of the benefits of breastfeeding, but their infant feeding journeys were more stressful than they expected, and they had limited access to lactation support and breastfeeding education/information. IBCLCs identified the benefits of the Baby-Friendly maternity care practices but mentioned some risks, especially when there is a lack of communication and coordination among providers. Environmental and informational barriers were identified by both postpartum individuals and IBCLCs as breastfeeding challenges potentially amenable to change. CONCLUSIONS: To support postpartum mothers in the Appalachian region, environmental barriers (eg, lack of lactation support) and informational barriers (eg, lack of prenatal education) need to be addressed.

Influences of a Remote Monitoring Program of Home Nasogastric Tube Feeds on Transition from NICU to Home.

OBJECTIVE: The transition from the neonatal intensive care unit (NICU) to the home is complex and multifaceted for families and infants, particularly those with ongoing medical needs. Our hospital utilizes a remote monitoring program called Growing @ Home (G@H) to support discharge from the NICU with continued nasogastric tube (NGT) feeds. We aim to describe the experience of the transition from NICU to home for families enrolled in G@H. STUDY DESIGN: Using a semistructured interviewing technique, parents of infants discharged on G@H were interviewed at NICU discharge, at 1 month, and at 6 months after NICU discharge. Interviews were recorded and transcribed into data analysis software. Conventional content analysis was used to analyze qualitative data. Codes were assigned to describe key elements of the interviews and used to identify major themes. RESULTS: Parents (n = 17) identified three major themes when discussing the effect of G@H on the transition to home. The program provided a means of escape from the NICU, allowing families to stop living split lives between their homes and the NICU. It acted as a middle ground between the restrictive yet supportive NICU environment, and the normal yet isolated home environment. G@H served as a safety net for families, providing a continued connection to the NICU for their still-fragile infants. CONCLUSION: G@H utilizes telehealth to positively support the complex transition from NICU to home for families and infants discharged with NGT feeds. KEY POINTS: · G@H program supported parents in their transition from NICU to home.. · G@H program provided a means of escape from the NICU.. · G@H program was a middle ground between the NICU and home.. · G@H program created a safety net after discharge.. · Follow-up with a consistent provider was essential to a positive parent experience..

Current state of home health in children with medical complexity.

BACKGROUND: Home health services are a right for children in the US, but higher survival rates of extremely preterm infants have led to an increase in children with medical complexity (CMC) and therefore an increased demand for home health services. Unfortunately, an adequately trained and compensated workforce to support medially complex children at home does not exist. METHODS: After identifying the existing research, common themes were identified. This article was written to give an overview of these themes and highlight specific supporting data. RESULTS: A lack of resources in the home health arena and the financial barriers that accompany them, as well as the clear impact this issue has on the health and well-being of families and caregivers, were frequently present in the literature. CONCLUSIONS: Reasonable next steps for research and advocacy include a focus on recruitment and retention of home health nurses, as well as training specific to the level of skill required to adequately care for CMC. Further research is needed, as in our search we found several unexplored, unassessed avenues that could help health care professionals understand the problem more fully. These steps are necessary if we want CMC to live the healthiest life available to them.

Exploring Parent Experiences With Early Palliative Care Practices in the NICU.

BACKGROUND: The anxiety and uncertain outcome of an admission of a seriously ill infant to the neonatal intensive care unit (NICU) can cause great stress for parents and contribute to poor mental health outcomes. Early implementation of family-centered palliative care (PC) may provide support for NICU parents. Key concepts of early PC in the NICU include shared decision-making, care planning, and support for coping with distress. PURPOSE: The purpose of this study was to explore parent experiences during their child's NICU admission with the early PC practices of shared decision-making, care planning, and coping with distress. METHODS: Qualitative descriptive methodology was used. Strategies of reflexive journaling, peer debriefing, and data audits were used to enhance trustworthiness. Parents (N = 16) were interviewed, and data were analyzed by conventional content analysis. Targeted recruitment of fathers occurred to ensure they comprised 25% of sample. RESULTS: Parents' descriptions of decision-making were contextualized in gathering information to make a decision, the emotional impact of the decision, and influences on their decision-making. In experiences with care planning, parents described learning to advocate, having a spectator versus participant role, and experiencing care planning as communication. Key themes expressed regarding parental coping were exposure to trauma, survival mode, and a changing support network. IMPLICATIONS FOR PRACTICE AND RESEARCH: These findings highlight key areas for practice improvement: providing more support and collaboration in decision-making, true engagement of parents in care planning, and encouraging peer support and interaction in the NICU and in online communities.

What factors are associated with anaemia in pregnancy among Nigerian women? Evidence from a national survey.

Background: Anaemia in pregnancy remains a severe public health problem in sub-Saharan African countries including Nigeria. Objectives: To assess factors associated with anaemia in pregnancy among Nigerian women. Methods: A secondary analysis of the 2018 Nigeria demographic health survey was conducted to determine the predictors of anaemia among Nigerian pregnant women (N=1522). SAS 9.4 was used for the analysis. Results: The prevalence of anaemia in pregnancy was 61.1%. On multivariable logistic regression analysis, women in the North-central (AOR=2.52, CI=1.46-4.35) and South-south (AOR=2.21, CI=1.06-4.59) had increased odds of anaemia in pregnancy, compared to those in the Northwest. Women with no education (AOR=2.38, CI=1.28-4.44), primary education (AOR=3.06, CI=1.58-5.96) and secondary education (AOR=1.75, CI=1.04-2.94) had increased odds of anaemia in pregnancy compared to women with teriary education. Also, women not in marital union had increased odds of anaemia in pregnancy compared to women in a union (AOR=2.56, CI=1.15-5.72). Women in the second (AOR=2.42, CI=1.79-3.29) and third trimesters of pregnancy (AOR=2.83, CI=2.07-3.89) had increased odds of anaemia. Conclusion: These findings are important for the control of anemia among pregnant Nigerian women. Women in the Northcentral and Southsouth zones are particularly at risk for anaemia in pregnancy and should receive special attention during antenatal care.

Neonatal Healthcare Professionals' Experiences When Implementing a Simulation and Debriefing Program in Neonatal Intensive Care Settings: A Qualitative Analysis.

BACKGROUND: Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment. PURPOSE: This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU). METHODS: Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes. RESULTS: There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support. IMPLICATIONS FOR PRACTICE AND RESEARCH: NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.

Acute resveratrol exposure does not impact hemodynamics of the fetal sheep.

Babies born growth restricted are at an increased risk of both poor short-and long-term outcomes. Current interventions to improve fetal growth are ineffective and do not lower the lifetime risk of poor health status. Maternal resveratrol (RSV) treatment increases uterine artery blood flow, fetal oxygenation, and fetal weight. However, studies suggest that diets high in polyphenols such as RSV may impair fetal hemodynamics. We aimed to characterize the effect of RSV on fetal hemodynamics to further assess its safety as an intervention strategy. Pregnant ewes underwent magnetic resonance imaging (MRI) scans to measure blood flow and oxygenation within the fetal circulation using phase contrast-MRI and T2 oximetry. Blood flow and oxygenation measures were performed in a basal state and then repeated while the fetus was exposed to RSV. Fetal blood pressure and heart rate were not different between states. RSV did not impact fetal oxygen delivery (DO2 ) or consumption (VO2 ). Blood flow and oxygen delivery throughout the major vessels of the fetal circulation were not different between basal and RSV states. As such, acute exposure of the fetus to RSV does not directly impact fetal hemodynamics. This strengthens the rationale for the use of RSV as an intervention strategy against fetal growth restriction.

A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care.

Background: Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC. Methods: A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems. Results: Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access). Conclusions: This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.

A National Survey Assessing the Variability in the Management of Traumatic Cardiac Arrest.

BACKGROUND: Resuscitation of traumatic cardiac arrest (TCA) is variable, with approaches that overlap Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) algorithms. There is no standard algorithm for TCA, with some withholding ACLS protocols given abysmal outcomes. This study aims to assess surgeon practices and attitudes toward resuscitation practices in TCA. MATERIALS AND METHODS: A 16-question web-based survey was distributed to the membership of a national trauma association. Respondent demographics and management of TCA were analyzed. Chi-squared tests determined statistical significance. Open-ended responses were coded and analyzed inductively. RESULTS: Two hundred and three surveys were completed. 73.4% of respondents reported utilizing ACLS, while 26.6% reported they never utilized ACLS. A statistically significant difference in the performance of ACLS was found based on number of years in practice (P = .025) and the state of practice (P = .006). There was no significant difference in self-reported survival rates or legal, ethical, or interpersonal conflicts. Qualitative data highlighted themes of interpersonal conflict and futility. DISCUSSION: This study shows that one-quarter of respondents never utilize ACLS in TCA. Of those that utilize ACLS, there was variability in the technique, indication, and duration of resuscitation. Despite significant variability in technique, there appears to be similar survival rates and incidence of conflict. The association between years in practice and ACLS use suggests this may represent an emerging change in practice. The low response rate limits generalizability; however, there is significant variability in practice, highlighting a need for evidence-based guidelines.

Neonatal Intensive Care Workflow Analysis Informing NEC-Zero Clinical Decision Support Design.

Decision support in neonatal ICUs is needed, especially for prevention and risk awareness of the devastating complication of necrotizing enterocolitis, a major cause of emergency surgery among fragile infants. The purpose of this study was to describe the current clinical workflow and sociotechnical processes among clinicians for necrotizing enterocolitis risk awareness, timely recognition of symptoms, and treatment to inform decision support design. A qualitative descriptive study was conducted. Focus groups were held in two neonatal ICUs (five groups in Unit A and six in Unit B). Transcripts were analyzed using content analysis and compared with field notes. Clinicians (N = 27) included nurses (37%), physicians (30%), neonatal nurse practitioners (19%), and other staff (16%). Workflow processes differed for nurses (who see necrotizing enterocolitis signs and notify providers to order diagnostic tests and treatments) and providers (who receive notification of necrotizing enterocolitis concern and then decide how to act). Clinicians desired (1) a necrotizing enterocolitis-relevant dashboard to support nutrition tracking and necrotizing enterocolitis recognition; (2) features to support decision-making (eg, necrotizing enterocolitis risk and adherence scoring); (3) breast milk tracking and feeding clinical decision support; (4) tools for necrotizing enterocolitis surveillance and quality reporting; and (5) general EHR optimizations to improve user experience.

Adversity in Infancy and Childhood Cognitive Development: Evidence From Four Developing Countries.

Objectives: We investigated whether adverse experiences at age 1 (AE-1) affect the level of and change in cognition during childhood using harmonized data from four developing countries. Methods: Data included children born in 2001/2002 and were followed longitudinally in 2006/2007 and in 2009/2010 by Young Lives study in Ethiopia, India, Peru, and Vietnam. Childhood cognition was measured using the Peabody Picture Vocabulary Test (PPVT) at ages 5 (PPVT-5) and 8 (PPVT-8). We also examined the effect on a change in cognition between age 5-8 (PPVT-Change). The AE-1 scores were constructed using survey responses at age 1. The ordinary least squares regression was used for estimation. Results: We found that children with higher adversities as infants had lower cognition scores at ages 5 and 8. The change in cognition between the two ages was also generally smaller for those with severe adversities at infancy. The negative association between adversities and childhood cognition was strongest for India. Conclusion: The results provide policy relevant information for mitigation of undesirable consequences of early life adversities through timely interventions.

MRI Characterization of Blood Flow and Oxygen Delivery in the Fetal Sheep whilst Exposed to Sildenafil Citrate.

INTRODUCTION: Newborns exposed to sildenafil citrate (SC) in utero have increased rates of persistent pulmonary hypertension. The mechanism behind this has not yet been fully elucidated. We aimed to utilize a combination of clinically relevant MRI techniques to comprehensively characterize the haemodynamics of the fetal sheep whilst under the influence of SC. We hypothesized that these MRI techniques would detect SC-induced increases in pulmonary blood flow and oxygen delivery prior to birth. METHODS: At 116-117 days gestational age (term, 150 days), pregnant Merino ewes (n = 9) underwent fetal catheterization surgery. MRI scans were performed during a basal state and then repeated during a constant umbilical vein infusion of SC to measure blood flow and oxygenation within the major vessels of the fetal circulation using phase-contrast-MRI and T2 oximetry. RESULTS: Right and left ventricular cardiac outputs were not different between states. Pulmonary blood flow increased during the SC state resulting in elevated pulmonary oxygen delivery. Right to left heart shunting through the foramen ovale was reduced without reducing cerebral oxygen delivery. CONCLUSION: SC induces alterations to pulmonary haemodynamics in utero; a characteristic that if maintained may underlie or act as a precursor towards the elevated rates of poor pulmonary outcomes after birth. These MRI techniques are the first to comprehensively characterize sildenafil's direct impact on the pulmonary vasculature and its indirect detriment to the flow of oxygen-rich blood through the foramen ovale.

Health Care Burden and Expenditure Associated with Adverse Childhood Experiences in Tennessee and Virginia.

To estimate attributable burden and costs of conditions associated with exposure to Adverse Childhood Experiences (ACEs) in Tennessee (TN) and Virginia (VA) during 2017. This is a cross-sectional study of individuals aged 18+ having exposure to ACEs using Behavioral Risk Factor Surveillance System (BRFSS) data. Eight chronic diseases (asthma, obesity, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), depression, cardiovascular disease, and arthritis) and two risk factors (smoking and drinking) associated with ACEs were analyzed. Pearson's chi-square tests analyzed the association between ACEs, risk factors and chronic diseases. The population attributable risks (PAR) were estimated for the ACEs related diseases and risk factors and combined with health care expenses and Disability Adjusted-Life-Years (DALYs). Among those who experienced at least 1 ACE in TN, 10% had COPD, 17% had diabetes, 36% had obesity, and 30% had depression. Individuals who experienced at least 1 ACE in VA had higher percentages for COPD, obesity and depression diseases compared to those who had no ACE (p< .0001). ACEs' exposure resulted in a burden of about 115,000 years and 127,000 years in terms of DALYs in TN and VA, respectively. The total health spending associated with ACEs based on PARs was about $647 million ($165 per adult) and $942 million ($292 per adult) in TN and VA respectively. The total costs associated with ACEs was about $15.5 billion ($3948) per person) and $20.2 billion ($6288 per person) in TN and VA, respectively. This study emphasizes the need to reduce ACEs due to high health and financial costs.

Impact of the Addition of a Centrifugal Pump in a Preterm Miniature Pig Model of the Artificial Placenta.

The recent demonstration of normal development of preterm sheep in an artificial extrauterine environment has renewed interest in artificial placenta (AP) systems as a potential treatment strategy for extremely preterm human infants. However, the feasibility of translating this technology to the human preterm infant remains unknown. Here we report the support of 13 preterm fetal pigs delivered at 102 ± 4 days (d) gestation, weighing 616 ± 139 g with a circuit consisting of an oxygenator and a centrifugal pump, comparing these results with our previously reported pumpless circuit (n = 12; 98 ± 4 days; 743 ± 350 g). The umbilical vessels were cannulated, and fetuses were supported for 46.4 ± 46.8 h using the pumped AP versus 11 ± 13 h on the pumpless AP circuit. Upon initiation of AP support on the pumped system, we observed supraphysiologic circuit flows, tachycardia, and hypertension, while animals maintained on a pumpless AP circuit exhibited subphysiologic flows. On the pumped AP circuit, there was a progressive decline in umbilical vein (UV) flow and oxygen delivery. We conclude that the addition of a centrifugal pump to the AP circuit improves survival of preterm pigs by augmenting UV flow through the reduction of right ventricular afterload. However, we continued to observe the development of heart failure within a matter of days.

They Built My Soul: A Qualitative Analysis of the Impacts of Home Repairs in Rural Tennessee.

Background: Housing is an important social determinant of health and substandard housing is linked to physical, mental, and social health problems. Purpose: The purpose of the study was to qualitatively assess the impacts of repairs to substandard housing in rural East Tennessee through twenty-eight interviews. Methods: Zoom was utilized for recording phone interviews in January-February 2021 and NVivo software was used for thematic analysis in May-July 2021. Results: Themes that emerged included environmental risk reduction, impacts on physical health, impacts on mental health, impacts on financial well-being, and willingness to receive future assistance from service organizations. Implications: Further research is recommended to quantify impacts including effects on utilization of health care and community services, school and work attendance, and mental health impacts.

Motivational interviewing to improve self-management in youth with type 1 diabetes: A randomized clinical trial.

PURPOSE: Effective interventions are needed to help adolescents with T1D develop independent self-management skills to prevent commonly observed deterioration of disease self-management resulting in poor health outcomes. Using a prospective RCT design, we assessed the impact of a nurse-led education program based on motivational interviewing (MI) in youth with Type 1 diabetes (T1D). DESIGN AND METHODS: After parental consent and youth assent, we prospectively randomized 66 adolescents 13-18 years old with T1D to either usual care (every 3 months visit with pediatric endocrinologist) or usual care supplemented by 2 in-person and 4 follow-up phone calls with a nurse educator in a pediatric endocrinology clinic of the University Hospital Farhat Hached, Sousse, Tunisia. We used MI sessions to support youth general and disease specific self-management skills. Outcomes were change, between baseline and 6 months, in TRAQ (a validated measure of youth self-management) scores and HbA1c values. RESULTS: Mean TRAQ scores (based on a 5-point Likert scale) increased by 1.44 points (s.d. = 0.56) in the Intervention Group versus 0.26 points (s.d. = 0.34) in the control group (p < 0.001). The mean HbA1C value decreased in the intervention group by 0.95 units versus a decrease of 0.12 units in the control group (p = 0.047). CONCLUSION: We found that a brief, nurse-led MI-based educational intervention, integrated into specialty pediatric care, resulted in a significant improvement in both self-reported self-management skills and in HbA1c values. TRIAL REGISTRATION: Registered in ClinicalTrials.gov Identifier: NCT04798937.

The role of transport and telecommunications technology in the development of the Scottish Highlands and Islands Medical Service: a historical perspective.

The Highlands and Islands Medical Service (HIMS) was introduced across the Scottish Highlands and Islands region after the publication of the Dewar Report in 1913. It was the first state-funded medical service in the UK and one of the first in the world. The Dewar Committee recommended the establishment of HIMS following research into healthcare provision in the region, concluding that there was insufficient provision. Among Dewar's major findings were the lack of sufficient transport infrastructure, high transport costs and low availability, and the lack of telecommunication services. This historical study with current relevance has addressed the contribution of transport and telecommunication technologies to the overall success of the Highland and Islands Medical Service. We have considered the crucial role of developments in the transport and telecommunications industries in overcoming contemporaneous healthcare problems. Through the study of contemporary letters, newspaper articles and government reports, this study assesses whether the views expressed at the time agree with the central contention that automobiles and telecommunication services were essential to the success of HIMS. This study also assesses the parallels drawn between the problems faced by HIMS in the 1900s and modern-day rural healthcare providers. Automobile use allowed those in the Highlands and Islands to commute with far greater ease, indirectly allowing doctors and members of the healthcare team to travel to see patients further afield and in greater numbers due to reduced travelling time. Additionally, funds provided by other government departments as well as HIMS allowed telecommunication technology to develop in the region, resulting in improved communication between widely dispersed healthcare workers, thereby improving healthcare provision. Prior to the formation of HIMS, the Highlands and Islands region in Scotland struggled to provide sufficient health care to its residents. The formation of HIMS resulted in improved health care in the region while simultaneous developments in the transport and telecommunication industries occurred. Past scholars have established links between the transport and telecommunication industries and healthcare provision in several countries. This study has contributed to existing literature by providing an insight into the relationship between such services in the Highlands and Islands region as well as rural life in the early 1900s. To conclude, the development of the transport and telecommunications industries acted synergistically with HIMS to lead to success in provision of good health care in the region.