Kangaroo mother care utilization at stepdown ward of a tertiary care teaching hospital: a quality improvement study.

PURPOSE: India has the highest burden of preterm/low birth weight newborns. To tackle this, Kangaroo Mother Care (KMC) needs to be scaled up. We did a quality improvement (QI) study to increase KMC coverage to 80% and its utilization to at least 4 h/infant/day. METHODS: This study was conducted at a stepdown ward (KMC ward) of a tertiary care teaching institute over a period of four months. All babies with birth weight <2.5 kg were eligible. The QI team included faculty in-charge, one senior resident and three senior staff nurses. Potential barriers were listed using fish-bone analysis. Four possible interventions were identified (daily documentation of total KMC hours by doctor, providing KMC during all the nursing duty shifts, counseling and education to mothers and family members), introduced, and then subsequently tested by four Plan-Do-Study-Act (PDSA) cycles and sustenance was assessed over three months. RESULTS: A total of 93 infants were included in this QI study. During baseline phase, the KMC coverage was 50% which increased to 100% by the end of fourth PDSA cycle and remained 100% during the sustenance phase. During baseline period, KMC was given for ≥ 4 h in 18.8% (28 of 149) patient days which increased to 88.96% (137 of 154) during the sustenance phase. The mean KMC utilization increased from 1.97 (1.57) h/infant/day to 5.65 (1.20) h/infant/day in the sustenance phase. CONCLUSION: QI study incorporating PDSA cycles helped improve coverage and utilization of KMC.

Efficacy of skin-to-skin vs. cloth-to-cloth contact for thermoregulation in low birth weight newborns: a randomized crossover trial.

OBJECTIVE: Skin-to-skin contact (SSC) is effective to maintain normal temperature in low birth weight (LBW) newborns. However, there are several barriers related to privacy and space availability for its optimum utilization. We used cloth-to-cloth contact (CCC), i.e. placing the newborn in Kangaroo position without removing cloths as an innovative alternative to SSC to test its efficacy for thermoregulation and feasibility as compared to SSC in LBW newborns. METHODS: The newborns eligible for Kangaroo Mother Care (KMC) in step-down nursery were included in this randomized crossover trial. Newborns received SSC or CCC as per randomization on the first day and then crossed over to other group on the next day and so on. A feasibility questionnaire was asked to the mothers and the nurses. Axillary temperature was measured at various time intervals. Group comparisons were made by either using independent sample t-test or Chi-square test. RESULTS: A total of 23 newborns received KMC for total 152 occasions in the SSC group and 149 times in the CCC group. There was no significant temperature difference between the groups at any time-point. Mean (standard deviation) gain of temperature at 120 min in the CCC group [0.43 (0.34)°C] was comparable to the SSC group [0.49 (0.36)°C] (p = 0.13). We did not observe any adverse effect of CCC. Most mothers and nurses perceived CCC feasible in hospital settings and felt that it could be feasible in-home settings too. CONCLUSION: CCC was safe, more feasible and not inferior to SSC for maintaining thermoregulation in LBW newborns.

Skin-to-skin contact (SSC) helps in maintaining optimum temperature of low birth weight (LBW) newborns. It is an important component of Kangaroo Mother Care (KMC), which is standard of care and reduces several neonatal morbidities and mortality. However, there are several barriers for the optimum utilization of KMC. One of the major barriers is privacy issues while putting newborn in SSC. To overcome this barrier for increasing KMC uptake, we innovatively thought of keeping the newborn on mother's chest without removing the cloths of both the mother and the newborn. We called it cloth-to-cloth contact (CCC). We compared SSC and CCC for temperature regulation in the newborns weighing between 1500 and 2499 g at the time of enrollment using a crossover design. We observed that mean temperature steadily increased in newborns while receiving SSC or CCC for 2 h. There were no significant differences in mean temperature readings between these two groups at various time points. Thus, CCC was not inferior to SSC in maintaining temperature. We did not observe any adverse effect of CCC. CCC may overcome the barrier of privacy issues of SSC. Thus, CCC was equally efficacious, safe and more feasible for maintaining thermoregulation in LBW newborns.

Pulse versus nonpulse steroid regimens in patients with coronavirus disease 2019: A systematic review and meta-analysis.

Systemic steroids are associated with reduced mortality in hypoxic patients with coronavirus disease 2019 (COVID-19). However, there is no consensus on the doses of steroid therapy in these patients. Several studies showed that pulse dose steroids (PDS) could reduce the progression of COVID-19 pneumonia. However, data regarding the role of PDS in COVID-19 is still unclear. Therefore, we performed this meta-analysis to evaluate the role of PDS in COVID-19 patients compared to nonpulse steroids (NPDS). Comprehensive literature search of PubMed, Embase, Cochrane Library, and Web of Science databases from inception through February 10, 2022 was performed for all published studies comparing PDS to NPDS therapy to manage hypoxic patients with COVID-19. Primary outcome was mortality. Secondary outcomes were the need for endotracheal intubation, hospital length of stay (LOS), and adverse events in the form of superimposed infections. A total of 10 observational studies involving 3065 patients (1289 patients received PDS and 1776 received NPDS) were included. The mortality rate was similar between PDS and NPDS groups (risk ratio [RR]: 1.23, 95% confidence interval [CI]: 0.92-1.65, p = 0.16). There were no differences in the need for endotracheal intubation (RR: 0.71, 95%: CI 0.37-1.137, p = 0.31), LOS (mean difference: 1.93 days; 95% CI: -1.46-5.33; p = 0.26), or adverse events (RR: 0.93, 95% CI: 0.56-1.57, p = 0.80) between the two groups. Compared to NPDS, PDS was associated with similar mortality rates, need for endotracheal intubation, LOS, and adverse events. Given the observational nature of the included studies, randomized controlled trials are warranted to validate our findings.

An implementation framework and a feasibility evaluation of a clinical decision support system for diabetes management in secondary mental healthcare using CogStack.

BACKGROUND: Improvements to the primary prevention of physical health illnesses like diabetes in the general population have not been mirrored to the same extent in people with serious mental illness (SMI). This work evaluates the technical feasibility of implementing an electronic clinical decision support system (eCDSS) for supporting the management of dysglycaemia and diabetes in patients with serious mental illness in a secondary mental healthcare setting. METHODS: A stepwise approach was taken as an overarching and guiding framework for this work. Participatory methods were employed to design and deploy a monitoring and alerting eCDSS. The eCDSS was evaluated for its technical feasibility. The initial part of the feasibility evaluation was conducted in an outpatient community mental health team. Thereafter, the evaluation of the eCDSS progressed to a more in-depth in silico validation. RESULTS: A digital health intervention that enables monitoring and alerting of at-risk patients based on an approved diabetes management guideline was developed. The eCDSS generated alerts according to expected standards and in line with clinical guideline recommendations. CONCLUSIONS: It is feasible to design and deploy a functional monitoring and alerting eCDSS in secondary mental healthcare. Further work is required in order to fully evaluate the integration of the eCDSS into routine clinical workflows. By describing and sharing the steps that were and will be taken from concept to clinical testing, useful insights could be provided to teams that are interested in building similar digital health interventions.

Efficacy of Skin-to-Skin Care versus Swaddling for Pain Control Associated with Vitamin K Administration in Full-Term Neonates: A Randomized Controlled Trial.

OBJECTIVE: The objective of the study was to assess the efficacy of immediate skin-to-skin care (SSC) versus swaddling in pain response to intramuscular injection of vitamin K at 30 min of birth in neonates. METHODS: Healthy full-term newborns were enrolled immediately after normal vaginal delivery and randomized in two groups, SSC and swaddling. Neonatal Infant Pain Scale (NIPS) was measured before, immediately after and at 2 min after the injection. RESULTS: Total 100 newborns were enrolled in the study (50 in each group). The mean (SD) birth weight of newborns in the SSC and swaddling group was 2668 (256) and 2730 (348) g, respectively. NIPS was comparable between the SSC and swaddling at before [1.78 (0.58) vs. 1.96 (0.83), p = 0.21], and immediately after the injection [4.82 (0.72) vs. 5.08 (0.75), p = 0.08]. NIPS at 2 min after the injection was significantly low in the SSC group compared to the swaddling group [1.38 (0.70) vs. 2.88 (1.00), p < 0.001]. At 2 min after injection, the NIPS score was significantly lower than baseline in the SSC group (p = 0.002), while it was significantly higher in the swaddling group (p < 0.001). A significantly higher proportion of newborns had a NIPS score of more than three at 2 min after injection in the swaddling group as compared to the SSC group (22% vs. 2%, p < 0.001). CONCLUSION: Immediate SSC was more efficacious as compared to swaddling as a pain control intervention while giving vitamin K injection. CLINICAL TRIAL REGISTRATION: The trial is registered with the Clinical Trial Registry of India with Registration number: CTRI/2020/01/022984.

Skin-to-skin care and swaddling are commonly used non-pharmacological measures to reduce pain perception in neonates for invasive procedures like heel prick, venipuncture and vaccination. We did this randomized control trial to compare the efficacy of immediate skin-to-skin care after birth vs. swaddling for reducing neonatal pain associated with intramuscular injection of vitamin K at 30 min after birth. We observed that the immediate skin-to-skin care, a standard of care, is more efficacious in controlling pain compared to swaddling for giving routine intramuscular vitamin K injection within one hour of birth.

Phosphodiesterase Type-5 Inhibitor Prescription Patterns in the United States Among Men With Erectile Dysfunction: An Update.

BACKGROUND: While phosphodiesterase type-5 inhibitors (PDE5Is) are highly effective for the treatment of erectile dysfunction (ED) and well tolerated, updated data on prescription patterns have been limited in real-world settings. AIM: To describe men in the United States who are prescribed PDE5Is for ED treatment and to evaluate patterns of initiation, switching, and treatment overlap. METHODS: This retrospective claims study used MarketScan Commercial and Medicare Supplement Databases from January 1, 2010, to December 31, 2015, to identify initial PDE5I claims (index date) for sildenafil, tadalafil, and/or vardenafil. Adults aged ≥18 years with ED were identified between July 1, 2010, and December 31, 2014, allowing for a 6-month preindex and 12-month follow-up period from the index date. OUTCOMES: Outcomes included patient demographics and treatment-related patterns after treatment initiation. RESULTS: A total of 106,206 identified patients met all inclusion criteria. Of these, 51,694, 40,193, and 14,319 had initial claims for sildenafil, tadalafil, and vardenafil, respectively. Mean age was 50.35 years, and comorbidities included dyslipidemia (44.17%), hypertension (43.09%), diabetes (15.32%), and depression (10.61%). More patients (48.67%) initiated on sildenafil than tadalafil (37.85%) or vardenafil (13.48%). Rate of switching was lower in the 60 days after the end of day supply of the initial prescription in the sildenafil cohort (2.71%) compared with the tadalafil (2.81%) and vardenafil (3.88%) cohorts (P < .001 for sildenafil vs tadalafil or vardenafil). Treatment overlap was lower in the sildenafil cohort (0.35%) than in the tadalafil (0.75%) and vardenafil (0.62%) groups (P < .001 for sildenafil vs tadalafil or vardenafil). CLINICAL IMPLICATIONS: These findings provide insight into updated patterns of PDE5I prescriptions in the United States and may aid in clinical decision-making. STRENGTHS & LIMITATIONS: Strengths include the large sample size, long data coverage period, and the real-world nature of the study. Limitations include the retrospective study design, use of data collected with a primary focus of claims, and lack of further details regarding reasons that drive switching. Actual rates of ED and impact on prescription patterns may be underestimated because the claims database only captured patients electing to visit a health-care provider. CONCLUSION: Among men with ED in the United States, rates of switching and treatment overlap were low for all PDE5Is but were found to be the lowest for sildenafil compared with tadalafil and vardenafil. Mulhall JP, Chopra I, Patel D, et al. Phosphodiesterase Type-5 Inhibitor Prescription Patterns in the United States Among Men With Erectile Dysfunction: An Update. J Sex Med 2020;17:941-948.

Cost-Effectiveness of Alemtuzumab in the Treatment of Relapsing Forms of Multiple Sclerosis in the United States.

OBJECTIVE: To evaluate the cost-effectiveness of alemtuzumab compared with fingolimod, natalizumab, ocrelizumab, and generic glatiramer acetate 20 mg among patients with relapsing multiple sclerosis (RMS) in the United States. STUDY DESIGN: Markov model with annual periods from payer perspective. METHODS: The modeled population represented pooled patients from the CARE-MS I and II trials. Therapies' comparative efficacy at reducing relapses and slowing disability worsening was obtained from network meta-analyses. Safety information was extracted from package inserts. Withdrawal rates, treatment waning, resource use, cost, and utility inputs were derived from published studies and clinical expert opinion. To project the natural history of disease worsening, data from the British Columbia cohort was used. RESULTS: Alemtuzumab dominated comparators by accumulating higher total quality-adjusted life-years (QALYs) (8.977) and lower total costs ($421 996) compared with fingolimod (7.955; $1 085 814), natalizumab (8.456; $1 048 599), ocrelizumab (8.478; $908 365), and generic glatiramer acetate (7.845; $895 661) over a 20-year time horizon. Alemtuzumab's dominance was primarily driven by savings in treatment costs because alemtuzumab has long-term duration of response and is initially administered as 2 annual courses, with 36.1% of patients requiring retreatment over 5 years, whereas comparators are used chronically. In model scenarios where alemtuzumab's long-term duration of response was assumed not to hold and therapy had to be administered annually, probabilistic sensitivity analyses showed that alemtuzumab remained cost-effective versus ocrelizumab at a willingness-to-pay threshold of $100 000/QALY in 74% to 100% of model runs. CONCLUSIONS: Alemtuzumab was a cost-effective therapy. Model results should be used to optimize clinical and managed care decisions for effective RMS treatment.

Efficacy of Polyethylene Skin Wrapping in Preventing Hypothermia in Preterm Neonates (<34 Weeks): A Parallel Group Non-blinded Randomized Control Trial.

OBJECTIVE: The objective of this study was to determine the efficacy of polyethylene skin wrapping on thermoregulation in preterm neonates. METHODS: Total 151 neonates were enrolled in this randomized control trial. In the control group, neonates were transferred to the radiant warmer and covered with warm cloth after initial care. In the study group, neonates were transferred to the radiant warmer and placed in a food-grade polyethylene bag for 1 h. Axillary temperature of all neonates was recorded for first 24 h at frequent time intervals. RESULTS: Mean temperature reached to normal range earlier and remained significantly higher in the study group for most time intervals, and this difference persisted even at 24 h. Significantly less number of preterm newborns suffered from hypothermia in the study group as compared with the control group [50 (67.6%) vs. 67 (87%), p = 0.004]. CONCLUSIONS: Polyethylene wraps achieved rapid, sustained thermal control and were effective in preventing hypothermia in preterm newborns.

An Educational Intervention to Improve Nurses' Understanding of Pain in Children in Western India.

Accurate assessment of pain and its management is a challenging aspect of pediatric care. Nurses, usually the primary caregivers, showed inadequate knowledge and restrictive attitudes toward pain assessment. We evaluated an educational intervention to improve nurses' assessment of pain in a teaching hospital in India. A convenient sample of nurses working in the neonatal intensive care unit, pediatric ward, pediatric intensive care unit, and pediatric cardiac intensive care unit were included in the study. Workshops to improve understanding of pain, its assessment, and management strategies were conducted. A modified and consensually validated Knowledge and Attitudes Survey Regarding Pain questionnaire-2008 consisting of 25 true/false questions, eight multiple choice questions, and two case scenarios was administered before, immediately after, and 3 months after the workshops to evaluate impact of the intervention. Eighty-seven nurses participated. Mean (standard deviation) experience was 4.04 (5.9) years. Thirty-seven percent felt that they could assess pain without pain scales. About half (49.4%) of the nurses had not previously heard of pain scales, while 47.1% reported using a pain scale in their routine practice. Significant improvement was observed between pretest and post-test total scores (15.69 [2.94] vs. 17.51 [3.47], p < .001) as well as the pretest and retention score (15.69 [2.94] vs. 19.40 [4.6], p < .001). Albeit the study site and sampling frame may limit the reliability of the findings, the educational intervention was successful, and better retention test scores suggest a cascading effect. Pain assessment and management education of children should be incorporated in the nursing curriculum and should be reinforced in all pediatric units.

Umbilical Venous Catheter Versus Peripherally Inserted Central Catheter in Neonates: A Randomized Controlled Trial.

Peripherally inserted central catheter (PICC) and umbilical venous catheter (UVC) in terms of success rate, complications, cost and time of insertion in neonatal intensive care were compared. Neonates requiring vascular access for minimum 7 days were included. Sample size of 72 per group was determined. Trial was registered at Clinical Trials Registry of India (CTRI/2015/02/005529). Success rates of the UVC and PICC were 68.1% and 65.3%, respectively (p = 0.724). Mean (SD) time needed for PICC and UVC insertion was 34.13 (34.69) and 28.31 (17.19) min, respectively (p = 0.205). Mean (SD) cost of PICC insertion vs. UVC insertion was 60.9 (8.6) vs. 11.9 (8.7) US dollars (p < 0.0001). Commonest cause for failure of UVC was displacement [6 (8.3%)] and that for PICC was blockage [9 (12.5%)]. CONCLUSIONS: UVC is a cheaper alternative to PICC, with similar success rate, short-term complications and time needed for insertion.

The presence of physician champions improved Kangaroo Mother Care in rural western India.

AIM: This study determined the effect of physician champions on the two main components of Kangaroo Mother Care (KMC): skin-to-skin care and breastfeeding. METHODS: KMC practices among a retrospective cohort of 648 infants admitted to a rural Indian neonatal intensive care unit (NICU) between January 5, 2011 and October 7, 2014 were studied. KMC champions were identified based on their performance evaluation. We examined the effect of withdrawing physician champions on overall use, time to initiation and intensity of skin-to-skin care and breastfeeding, using separate models. RESULTS: In comparison with when KMC champions were present, their absence was associated with a 45% decrease in the odds of receiving skin-to-skin care, with a 95% confidence interval (CI) of 64% to 17%, a 38% decrease in the rate of initiation skin-to-skin care (95% CI 53-82%) and an average of 1.47 less hours of skin-to-skin care (95% CI -2.07 to -0.86). Breastfeeding practices were similar across the different champion environments. CONCLUSION: Withdrawing physician champions from the NICU setting was associated with a decline in skin-to-skin care, but not breastfeeding. Training health care workers and community stakeholders to become champions could help to scale up and maintain KMC practices.

Symptomatic retethering of the spinal cord in postoperative lipomyelomeningocele patients: a meta-analysis.

BACKGROUND: Timing of surgical treatment for tethered cord syndrome due to a lipomyelomeningocele (LMM) has been controversial. The purpose of this study was to evaluate populations of patients treated surgically for LMM in a meta-analysis in order to better understand how outcomes differ based on follow-up time, symptomatology, and LMM classification. METHODS: An extensive search on PubMed and Google Scholar was performed for LMM and surgical outcomes to identify case series of patients for inclusion in this analysis. Patients were sorted based upon symptomatology prior to surgery and Chapman's LMM classification, where possible. Deterioration rates were determined by symptomatic retethering of the spinal cord that led to repeat surgery. RESULTS: Of 608 (19 %) patients, 115 were included in the study experienced deterioration leading to repeat surgery. Symptomatic and asymptomatic patients did not experience significantly different rates of deterioration after surgical untethering. There was a significant positive linear correlation between follow-up time of studies and percentage of patients deteriorating with an increase of 3.3 % per year of follow-up. Transitional LMM had a significantly higher rate of deterioration compared to the caudal type along with the entire patient pool. CONCLUSIONS: Outcomes of primary surgical treatment in regard to late deterioration are not significantly affected by patient symptomatology. Patient deterioration increases linearly over time. Additional studies should be performed to adequately determine the natural history of asymptomatic patients that are treated conservatively for LMM.

Beta-blockers in heart failure with preserved ejection fraction: a meta-analysis.

Beta-blockers are established drugs in heart failure with reduced ejection fraction, but their role in heart failure with preserved ejection fraction (HFpEF) is not established. Hence, we undertook a meta-analysis to evaluate the efficacy of beta-blockers on mortality and morbidity in HFpEF patients. A systematic search using PubMed, Embase, Scopus and Cochrane databases was performed to identify all relevant studies on beta-blockers and HFpEF. A random-effects model was performed to assess the role of beta-blockers on all-cause mortality and HF hospitalization. Overall 15 observational studies and two randomized control trial involving a total of 27,099 patients were included in the analysis. In the observational studies, beta-blocker therapy was associated with lower all-cause mortality [RR 0.81 (0.72-0.90), p < 0.001], but not HF hospitalization [RR 0.79 (0.57-1.10), p < 0.001]. However, in the two RCTs, the use of beta-blocker was not associated with all-cause mortality [RR 0.94 (0.67-1.32), p = 0.72] or HF hospitalization [0.90 (0.54-1.49), p = 0.68]. The results were consistent by geographic region (USA vs. rest of world) and ejection fraction subgroups. Subgroup analysis revealed that the beneficial survival effect of beta-blocker was limited to studies with mean age <75 years. Observational studies showed a significant benefit from the use of beta-blockers for all-cause mortality, but not for HF hospitalization. Beta-blockers in the two RCTs were not associated with significant reduction in all-cause mortality or HF hospitalization; however, both the trials were not adequately powered and had high loss to follow-up rates. Further large sampled well-conducted randomized trials are warranted to confirm the effects of beta-blockers on mortality and hospitalization.

Effects of BPA and BPS exposure limited to early embryogenesis persist to impair non-associative learning in adults.

BACKGROUND: Bisphenol-A (BPA) is a polymerizing agent used in plastic bottles and several routinely used consumer items. It is classified among endocrine disrupting chemicals suspected to cause adverse health effects in mammals ranging from infertility and cancer to behavioral disorders. Work with the invertebrate lab model Caenorhabditis elegans has shown that BPA affects germ cells by disrupting double-stranded DNA break repair mechanisms. The current study utilizes this model organism to provide insight into low-dose and long-term behavioral effects of BPA and bisphenol-S (BPS), a supposed safer replacement for BPA. FINDINGS: Experiments presented in our report demonstrate that the effects of embryonic exposure to considerably low levels of BPA persist into adulthood, affecting neural functionality as assayed by measuring habituation to mechano-sensory stimuli in C. elegans. These results are noteworthy in that they are based on low-dose exposures, following the rationale that subtler effects that may not be morphologically apparent are likely to be discernible through behavioral changes. In addition, we report that embryonic exposure to BPS follows a pattern similar to BPA. CONCLUSIONS: Building upon previous observations using the C. elegans model, we have shown that exposure of embryos to BPA and BPS affects their behavior as adults. These long-term effects are in line with recommended alternate low-dose chemical safety testing approaches. Our observation that the effects of BPS are similar to BPA is not unexpected, considering their structural similarity. This, to our knowledge, is the first reported behavioral study on low-dose toxicity of any endocrine disrupting chemical in C. elegans.

Modeling the economic impact of linezolid versus vancomycin in confirmed nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus.

INTRODUCTION: We compared the economic impacts of linezolid and vancomycin for the treatment of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA)-confirmed nosocomial pneumonia. METHODS: We used a 4-week decision tree model incorporating published data and expert opinion on clinical parameters, resource use and costs (in 2012 US dollars), such as efficacy, mortality, serious adverse events, treatment duration and length of hospital stay. The results presented are from a US payer perspective. The base case first-line treatment duration for patients with MRSA-confirmed nosocomial pneumonia was 10 days. Clinical treatment success (used for the cost-effectiveness ratio) and failure due to lack of efficacy, serious adverse events or mortality were possible clinical outcomes that could impact costs. Cost of treatment and incremental cost-effectiveness per successfully treated patient were calculated for linezolid versus vancomycin. Univariate (one-way) and probabilistic sensitivity analyses were conducted. RESULTS: The model allowed us to calculate the total base case inpatient costs as $46,168 (linezolid) and $46,992 (vancomycin). The incremental cost-effectiveness ratio favored linezolid (versus vancomycin), with lower costs ($824 less) and greater efficacy (+2.7% absolute difference in the proportion of patients successfully treated for MRSA nosocomial pneumonia). Approximately 80% of the total treatment costs were attributed to hospital stay (primarily in the intensive care unit). The results of our probabilistic sensitivity analysis indicated that linezolid is the cost-effective alternative under varying willingness to pay thresholds. CONCLUSION: These model results show that linezolid has a favorable incremental cost-effectiveness ratio compared to vancomycin for MRSA-confirmed nosocomial pneumonia, largely attributable to the higher clinical trial response rate of patients treated with linezolid. The higher drug acquisition cost of linezolid was offset by lower treatment failure-related costs and fewer days of hospitalization.

Effect of skin to skin care to neonates on pulse rate, respiratory rate SPO2 and blood pressure in mothers.

Physiological benefits of skin to skin care (STS) to newborns are known but there is scarcity of data on changes in physiological parameters like pulse rate, respiratory rate, SPO2 and blood pressure in mothers during STS. We hypothesize that STS is beneficial to mothers with respect to these parameters. Objective of this study was to assess the changes of these parameters in mothers while providing STS for one hour. STS was provided by 52 mothers for a total of 127 times and parameters were recorded at starting of STS, at 15 min, at 30 min, at 60 min of STS and at 5 min rest after stopping STS. There were no significant changes in pulse rate and SPO2 but blood pressure and respiratory rate reduced significantly during STS as compared to rest after stopping STS. Thus STS is physiologically beneficial to mothers.

Post-discharge home kangaroo mother care follow-up study in rural Gujarat.

Background: Continuation of kangaroo mother care (KMC) at home is vital for improved infant survival and development. Hence, it is essential to understand potential enablers and barriers to home KMC provision. Methodology: This observational study was conducted in rural Gujarat. KMC was initiated for all low-birth-weight (LBW) neonates during the hospital stay and were advised to continue home KMC on discharge. The mothers of these LBW neonates were interviewed using a structured questionnaire during follow-up visits or via telephone. Results: A total of 100 mothers were interviewed, and 98 practiced home KMC. Mothers' mean age was 24.41 (±3.1) years, and infants' mean age was 3.48 (±1.81) months. The mean weight of neonates at discharge was 1.85 (±0.28) kg. Out of the 104 neonates (96 singleton pregnancies and four twins), 76 (73.07%) were pre-term. 31% mothers provided 4-6 hours of daily KMC. 60% provided KMC for less than 1 hour during each session, while 36% of mothers provided each KMC session for 1-3 hours. 74% of mothers received family support, and 62% faced difficulties in home KMC provision. 88% of mothers were homemakers, and 53% had other children to care for. 51% mothers pre-maturely discontinued KMC provision. 83% of the mothers reported fatigue or pain during KMC provision. Conclusion: Lack of family support, other household responsibilities, and other children to care for were major barriers leading to pre-mature discontinuation of home KMC.

Evaluating Treatment Choice in Patients with Moderate to Severe Psoriasis in the United States: Results from a US Patient Survey.

INTRODUCTION: While multiple treatments are available for moderate to severe psoriasis, patient preferences are rarely systematically studied. This study aims to identify factors associated with choice of a new once-daily oral psoriasis treatment, elicit patient views on treatment characteristics, and rank treatment characteristics by importance. METHODS: This noninterventional, cross-sectional survey study, conducted from December 2021 to June 2022, recruited US adults with moderate to severe psoriasis. Demographics, clinical characteristics, and perspectives on psoriasis treatment were collected. Factors associated with the choice of a new oral treatment were identified using multivariable logistic regression analysis. Treatment characteristics and reasons for treatment choice were ranked using bivariate comparisons. RESULTS: The study included 882 participants [mean (standard deviation; SD) age, 45.7 (12.8) years; female, 67.7%; White, 74.9%]; 92.7% were currently receiving treatment [mean (SD) duration, 2.9 (4.8) years]. Half of participants rated their psoriasis symptoms over the past week as mild, very mild, or nonexistent; 36.5% as moderate; and 12.7% as severe or very severe. Most (66.5%) indicated willingness to start a new oral treatment; 65.0% indicated that the new oral treatment would cause less anxiety than injections/infusions. Participants were significantly more likely to start the new oral treatment if they were currently receiving a tumor necrosis factor inhibitor [odds ratio (OR): 2.1, 95% confidence interval (CI): 1.4-3.1] or ustekinumab (OR: 2.7, 95% CI: 1.6-5.0) versus apremilast (P < 0.001) or if they reported mild (OR: 3.2, 95% CI: 2.0-4.9), moderate (OR: 5.0, 95% CI: 3.1-8.2), or severe (OR: 7.6, 95% CI: 3.9-15.0) psoriasis symptoms compared with those who reported no symptoms in the past week (P < 0.001). CONCLUSION: Most participants indicated willingness to start a new once-daily oral treatment, viewing it as less anxiety provoking than injections/infusions. Current treatment and psoriasis severity affected participants' willingness to start a new oral treatment.

Patients with psoriasis have multiple treatment options available to them. We surveyed 882 adults with moderate to severe psoriasis in the US to assess their perspectives and the values placed on treatment characteristics that are most important to them when making treatment-related decisions. Participants were assigned to one of five groups based on their psoriasis treatment at the time of the survey: (1) apremilast (oral), (2) a tumor necrosis factor inhibitor (TNFi) treatment (injectable), (3) ustekinumab (injectable), (4) a topical therapy or phototherapy, or (5) over-the-counter medications or participants who were untreated (this group included those who were not currently using a psoriasis treatment). The extent of skin clearance associated with a drug, how a drug is taken, and a drug's safety profile were among the top-ranked treatment characteristics that are important to survey participants when they choose a psoriasis treatment. Most participants (66.5%) were willing to start a new oral treatment, with 65.0% indicating that the new oral treatment would cause less anxiety than injections or infusions. Participants were more willing to switch to a new oral psoriasis treatment if they were currently receiving an injectable treatment, such as ustekinumab or a TNFi, compared with those who were already taking an oral treatment. These findings suggest that, when prescribing treatments for psoriasis, health care providers should consider the treatment characteristics that are important to their patients and consider that patients generally prefer an oral versus injectable drug.

Implementation of an Electronic Clinical Decision Support System for the Early Recognition and Management of Dysglycemia in an Inpatient Mental Health Setting Using CogStack: Protocol for a Pilot Hybrid Type 3 Effectiveness-Implementation Randomized Controlled Cluster Trial.

BACKGROUND: Severe mental illnesses (SMIs), including schizophrenia, bipolar affective disorder, and major depressive disorder, are associated with an increased risk of physical health comorbidities and premature mortality from conditions including cardiovascular disease and diabetes. Digital technologies such as electronic clinical decision support systems (eCDSSs) could play a crucial role in improving the clinician-led management of conditions such as dysglycemia (deranged blood sugar levels) and associated conditions such as diabetes in people with a diagnosis of SMI in mental health settings. OBJECTIVE: We have developed a real-time eCDSS using CogStack, an information retrieval and extraction platform, to automatically alert clinicians with National Health Service Trust-approved, guideline-based recommendations for dysglycemia monitoring and management in secondary mental health care. This novel system aims to improve the management of dysglycemia and associated conditions, such as diabetes, in SMI. This protocol describes a pilot study to explore the acceptability, feasibility, and evaluation of its implementation in a mental health inpatient setting. METHODS: This will be a pilot hybrid type 3 effectiveness-implementation randomized controlled cluster trial in inpatient mental health wards. A ward will be the unit of recruitment, where it will be randomly allocated to receive either access to the eCDSS plus usual care or usual care alone over a 4-month period. We will measure implementation outcomes, including the feasibility and acceptability of the eCDSS to clinicians, as primary outcomes, alongside secondary outcomes relating to the process of care measures such as dysglycemia screening rates. An evaluation of other implementation outcomes relating to the eCDSS will be conducted, identifying facilitators and barriers based on established implementation science frameworks. RESULTS: Enrollment of wards began in April 2022, after which clinical staff were recruited to take part in surveys and interviews. The intervention period of the trial began in February 2023, and subsequent data collection was completed in August 2023. Data are currently being analyzed, and results are expected to be available in June 2024. CONCLUSIONS: An eCDSS can have the potential to improve clinician-led management of dysglycemia in inpatient mental health settings. If found to be feasible and acceptable, then, in combination with the results of the implementation evaluation, the system can be refined and improved to support future successful implementation. A larger and more definitive effectiveness trial should then be conducted to assess its impact on clinical outcomes and to inform scalability and application to other conditions in wider mental health care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT04792268; https://clinicaltrials.gov/study/NCT04792268. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49548.

Young Woman with Unexplained Neutropenia and Neutrophils with Bilobed Nuclei: Marrow Findings.

A 27-year-old female with a history of chronic sinusitis was referred for the evaluation of asymptomatic neutropenia. The differential demonstrated a mild neutropenia, which eventually resolved on subsequent evaluation. The liver and the spleen were not palpable. Peripheral flow cytometry was normal. Peripheral blood smear (PBS) demonstrated numerous Pelger-Huet anomalous neutrophils with characteristic "pince-nez" nuclei, without significant abnormalities in the other cell lines. Due to the benign clinical nature of hereditary PHA, a bone marrow biopsy is almost never required. However, our patient's persistent and worsening neutropenia was unusual for hereditary PHA, so a bone marrow biopsy was performed to rule out MDS and leukemia. Our patient's bone marrow smears showed dysplastic changes to other cell lines including the megakaryocytes and erythroid precursors. Due to our patient's young age and concern that she may have a more serious marrow disorder, genetic testing was pursued. Germline testing in the LBR gene revealed a heterozygous pathogenic mutation, namely, the PR57837.17 variant, confirming the diagnosis of hereditary disease. The bone marrow biopsy performed on our patient illustrates that the presence of dysplasia does not rule out hereditary PHA and further genetic testing should be done in the appropriate clinical scenario. This case was an atypical presentation of hereditary PHA with confounding morphological features that would typically classify the disease as an acquired or pseudo-PHA, hence acting as a Pseudo-Pseudo-Pelger-Huet Anomaly.