Evaluation of a breastmilk hand expression toolkit: the M.I.L.K survey study.

BACKGROUND: Breastmilk hand expression (BMHE) is recommended to promote lactation, relieve breast engorgement, and collect milk for future infant feedings. Resources to teach this skill are limited and infrequently developed in partnership with the obstetrical population. In collaboration with maternity care experts and individuals with recent breastfeeding experience, we designed a one-page toolkit that describes the process of BMHE and includes step-by-step instructions and images to illustrate the technique. This study aimed to evaluate the readability, clarity of content, layout, and informational value of this BMHE toolkit. METHODS: Individuals who intended to breastfeed, were currently breastfeeding, or had recently breastfed were electronically surveyed and completed a two-part survey that consisted of radio, multi-select, Likert scale, and open-ended questions. Part one captured sociodemographic factors, obstetrical history, and breastfeeding practices. Part two collected feedback on the BMHE toolkit. Participants were recruited electronically through social media and posters were circulated in antenatal and postnatal care settings in Ottawa, Canada between November 2020 and February 2021. RESULTS: Of the 123 participants, 117 (95.1%) had heard of hand expression prior to reviewing the toolkit and 99 (80.5%) had hand expressed before. Among the 48 participants who were no longer exclusively breastfeeding at the time of the survey, 22 (45.8%) had exclusively breastfed their infant for at least six months and 7 (14.6%) had discontinued exclusive breastfeeding within the first month. When asked about the BMHE toolkit, 118 (95.9%) participants said it was informative, 115 (93.5%) said it was easy to understand, and 114 (92.7%) said it was well laid-out. When asked about information seeking behaviours, participants indicated a preference for online resources (58.5%) and video resources (22.0%). CONCLUSIONS: The BMHE toolkit was well received by participants and the feedback was favourable overall. The survey feedback will be used to create a revised version of the toolkit that has been validated by the obstetrical patient population. Future research should focus on identifying implementation strategies to optimize the use of the toolkit and increase its effectiveness as an educational resource to teach participants correctly BMHE.

DRESS with delayed onset acute interstitial nephritis and profound refractory eosinophilia secondary to Vancomycin.

BACKGROUND: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a relatively rare clinical entity; even more so in response to vancomycin. METHODS: Case report. RESULTS: We present a severe case of vancomycin-induced DRESS syndrome, which on presentation included only skin, hematological and mild liver involvement. The patient further developed severe acute interstitial nephritis, eosinophilic pneumonitis, central nervous system (CNS) involvement and worsening hematological abnormalities despite immediate discontinuation of vancomycin and parenteral corticosteroids. High-dose corticosteroids for a prolonged period were necessary and tapering of steroids a challenge due to rebound-eosinophilia and skin involvement. CONCLUSION: Patients with DRESS who are relatively resistant to corticosteroids with delayed onset of certain organ involvement should be treated with a more prolonged corticosteroid tapering schedule. Vancomycin is increasingly being recognized as a culprit agent in this syndrome.

A case of antiphospholipid syndrome presenting cryptogenically as Budd-Chiari syndrome, then fulminantly as Libman-Sacks endocarditis.

A 58 year-old left-handed woman was transferred to our hospital with an evolving left middle cerebral artery stroke, severe thrombocytopenia and elevated inflammatory markers. She had a history of chronic Budd-Chiari syndrome (BCS) 16 months prior, attributed to a calcified web in the inferior vena cava that was stented. No thrombophilia testing was performed at that time. The current presentation demonstrated dense right-sided facial and arm paresis and neglect. Erythrocyte sedimentation rate and C-reactive protein were elevated, an autoimmune workup was consistent with a new diagnosis of systemic lupus erythematosus and triple-positive antiphospholipid antibodies. A transesophageal echocardiogram demonstrated a vegetation consistent with Libman-Sacks endocarditis (LSE), thought to have embolised to the brain. The patient was treated acutely with steroids, intravenous immunoglobulin and clopidogrel. This case demonstrates an atypical constellation of the antiphospholipid syndrome, with a novel presentation of BCS and LSE, and reinforces the importance of hypercoagulability screening in this population.

Management and Outcomes of Maturity-Onset Diabetes of the Young in Pregnancy.

Maturity-onset diabetes of the young (MODY) is a group of monogenic disorders that accounts for 1% to 5% of diabetes. The most common mutations are those in the hepatocyte nuclear factor-1-alpha (HNF-1-alpha) and in the glucokinase (GCK) genes. Although management of MODY is well established, no guidelines currently exist for management during pregnancy. Both maternal glycemic control and fetal mutation status are factors that may influence outcomes during pregnancy. The primary aim of this project was to describe cases of MODY during pregnancy to highlight the clinical implications of management of this disorder during pregnancy. The Ottawa Hospital is the primary referral centre for high-risk obstetrical patients, including those with diabetes in pregnancy, in Ottawa, Canada. Referrals between 2008 and 2018 were reviewed and a case series of three women and five pregnancies is described. Together with the illustrative cases, a literature review of MODY in pregnancy is used to highlight clinical considerations unique to MODY in pregnancy. We describe 5 pregnancies with MODY-2 (GCK mutation) and MODY 3 (HNF-1-alpha mutation). Important issues identified included monitoring of fetal growth and individualization of maternal glycemic control, particularly in cases where fetal mutation status is unknown. Management of MODY in pregnancy is challenging and there is little evidence to guide recommendations. Fetal growth can be used to guide management of maternal glycemic targets when fetal mutation status is unknown.