Neonatal Cardiac Emergencies: A Multidisciplinary Simulation Curriculum for Neonatology and Pediatric Cardiology Fellows.

Introduction: Although care for neonates with cardiac disease is frequently provided by neonatologists and pediatric cardiologists, training in the multidisciplinary management of neonatal cardiac emergencies is not often included in fellowship training. We created a multidisciplinary simulation curriculum to address the skills needed for neonatal cardiac care. Methods: Neonatology and pediatric cardiology fellows participated in 1-hour simulations on 3 different days. They managed a neonate with: (1) cyanosis, (2) cardiogenic shock, and (3) an unstable arrhythmia. Using both remote consultation and bedside evaluation, the participants diagnosed and jointly established a management plan for the infant. During the debrief, facilitators reviewed the clinical decisions and multidisciplinary management skills of the participants. Participants completed pre- and postparticipation surveys to evaluate the curriculum's effect on their confidence in the management of neonatal cardiac disease. Results: Thirty-three paired survey responses from 20 participants (11 neonatology and 9 pediatric cardiology) reported a mean overall satisfaction score of 4.6 (SD = 0.7) based on a 5-point Likert scale. Postparticipation confidence scores improved significantly in: (1) the recognition of the signs of congenital heart disease (pre = 4.1, post = 4.5, p = .01), (2) differentiation of cardiac cyanosis from noncardiac cyanosis (pre = 3.9, post = 4.2, p = .05), and (3) confidence in discussing cardiac concerns with consultants (pre = 3.3, post = 4.1, p = .02). Discussion: This multidisciplinary simulation improved fellows' confidence in the management of neonates with cardiac disease and provided an opportunity to practice team work, remote consultation, and cross-disciplinary communication.

The 3G Multigenerational Cohort of Nova Scotian women and their mothers and offspring.

BACKGROUND: The negative impact of exposures such as maternal obesity, excessive gestational weight gain, and hypertension in pregnancy on the health of the next generation has been well studied. Evidence from animal studies suggests that the effects of in utero exposures may persist into the second generation, but the epidemiological literature on the influence of pregnancy-related exposures across three generations in humans is sparse. OBJECTIVES: This cohort was established to investigate associations between antenatal and perinatal exposures and health outcomes in women and their offspring. POPULATION: The cohort includes women who were born and subsequently had their own pregnancies in the Canadian province of Nova Scotia from 1980 onward. DESIGN: Intergenerational linkage of data in the Nova Scotia Atlee Perinatal Database was used to establish a population-based dynamic retrospective cohort. METHODS: The cohort has prospectively collected information on sociodemographics, maternal health and health behaviours, pregnancy health and complications, and obstetrical and neonatal outcomes for two generations of women and their offspring. PRELIMINARY RESULTS: As of October 2018, the 3G cohort included 14 978 grandmothers (born 1939-1986), 16 766 mothers or cohort women (born 1981-2003), and 28 638 children (born 1996-2018). The cohort women were generally younger than Nova Scotian women born after 1980, and as a result, characteristics associated with pregnancy at a younger age were more frequently seen in the cohort women; sampling weights will be created to account for this design effect. The cohort will be updated annually to capture future deliveries to women who are already in the cohort and women who become eligible for inclusion when they deliver their first child. CONCLUSIONS: The 3G Multigenerational Cohort is a population-based cohort of women and their mothers and offspring, spanning a time period of 38 years, and provides the opportunity to study inter- and transgenerational associations across the maternal line.

Relative effectiveness and cost-effectiveness of the midwifery-led care in Nova Scotia, Canada: A retrospective, cohort study.

OBJECTIVES: To compare neonatal and maternal outcomes, and the relative risk of interventions between mothers attended to by midwives, general practitioners, and obstetricians, and to assess the cost-effectiveness of the employee-model of midwifery-led care in Nova Scotia, Canada, when compared with general practitioners. DESIGN, SETTING, AND PARTICIPANTS: The study was a retrospective cohort study involving routinely collected clinical and administrative data from all low-risk births from January 1st, 2013 to December 31st, 2017. There were 24,662 observations. MEASUREMENTS: Descriptive statistics were used to summarise the mother's socio-demographic characteristics. We used a nearest-neighbour matching estimator in assessing differences in outcomes, and generalized linear models in the estimation of the risks of interventions, adjusting for potential confounders. An analytic decision tree served as the vehicle for the cost-effectiveness analysis, assessed using the net monetary benefit approach. All health care resources utilized were measured and valued. Neonatal intensive care admissions avoided was the measure of outcome. We performed probabilistic sensitivity and subgroup analyses. FINDINGS: Mothers attended to by midwives spent less time at the hospital during birth admissions, were less likely to have interventions, instrumental births, and more likely to have exclusive breastfeeding at discharge from birth admission. There were no differences in Apgar scores and neonatal intensive care unit admissions. The employee-model of midwifery-led care was found to be cost-effective. KEY CONCLUSIONS: The midwifery program is both effective and cost-effective for low-risk pregnancies IMPLICATIONS FOR PRACTICE: Increasing the number of midwives will increase access and represents value for money.

Effects of socioeconomic position and clinical risk factors on spontaneous and iatrogenic preterm birth.

BACKGROUND: The literature shows a variable and inconsistent relationship between socioeconomic position and preterm birth. We examined risk factors for spontaneous and iatrogenic preterm birth, with a focus on socioeconomic position and clinical risk factors, in order to explain the observed inconsistency. METHODS: We carried out a retrospective population-based cohort study of all singleton deliveries in Nova Scotia from 1988 to 2003. Data were obtained from the Nova Scotia Atlee Perinatal Database and the federal income tax T1 Family Files. Separate logistic models were used to quantify the association between socioeconomic position, clinical risk factors and spontaneous preterm birth and iatrogenic preterm birth. RESULTS: The study population included 132,714 singleton deliveries and the rate of preterm birth was 5.5%. Preterm birth rates were significantly higher among the women in the lowest (versus the highest) family income group for spontaneous (rate ratio 1.14, 95% confidence interval (CI) 1.03, 1.25) but not iatrogenic preterm birth (rate ratio 0.95, 95% CI 0.75, 1.19). Adjustment for maternal characteristics attenuated the family income-spontaneous preterm birth relationship but strengthened the relationship with iatrogenic preterm birth. Clinical risk factors such as hypertension were differentially associated with spontaneous (rate ratio 3.92, 95% CI 3.47, 4.44) and iatrogenic preterm (rate ratio 14.1, 95% CI 11.4, 17.4) but factors such as diabetes mellitus were not (rate ratio 4.38, 95% CI 3.21, 5.99 for spontaneous and 4.02, 95% CI 2.07, 7.80 for iatrogenic preterm birth). CONCLUSIONS: Socioeconomic position and clinical risk factors have different effects on spontaneous and iatrogenic preterm. Recent temporal increases in iatrogenic preterm birth appear to be responsible for the inconsistent relationship between socioeconomic position and preterm birth.

Recent changes in maternal characteristics by socioeconomic status.

OBJECTIVE: To describe changes in maternal characteristics by socioeconomic status, in order to provide a context for recent changes in the frequency of obstetric procedures and outcomes, and information for health planning purposes. METHODS: All NS residents who delivered between 1988 and 2007 were included in the study. Information on maternal characteristics was obtained from the Nova Scotia Atlee Perinatal Database, and socioeconomic status information was obtained through a confidential link with federal income tax T1 Family Files (1988 to 2003). RESULTS: Total births to women < 20 years of age were high (31.5% in 2003) and increased in the lowest family income group between 1988 and 2003, while rates were low (0.7% in 2003) and decreased in the highest family income group. Total births to women >/= 35 years increased by 136% (95% CI 122, 150) between 1988-89 and 2006-07. Births to women with a weight >/= 90 kg also increased, while those to smokers decreased in all socioeconomic groups. The proportion of births to multiparous women with a previous low birth weight infant did not change (-5 %, 95% CI -14, 6), although births to women with a previous perinatal death declined by 52% (95% CI -60,-42). CONCLUSION: Large secular changes have occurred in maternal characteristics over the past two decades, and the magnitude of these changes has differed by socioeconomic status.

Is exercise stress testing a cost-saving strategy for risk assessment of pediatric wolff-Parkinson-white syndrome patients?

BACKGROUND: In Wolff-Parkinson-White syndrome (WPW) patients the loss of pre-excitation in a single heartbeat during exercise stress testing (EST) is a predictor of low risk of sudden death. The purpose of this study was to: 1) assess the frequency of loss of pre-excitation in a single heartbeat during exercise testing, and 2) compare the cost of EST versus trans-catheter electrophysiology study (EPS) in the risk assessment of WPW patients. METHODS: A retrospective review of 50 cases of patients with WPW who underwent EST was conducted including demographics, history of supraventricular tachycardia, associated congenital heart disease, maximum heart rate achieved, and loss of pre-excitation in a single heartbeat. Hospital costs of EST and EPS were compared. RESULTS: Of the 50 patients who underwent EST, 4 (8%), lost pre-excitation in a single heartbeat during EST. No differences were found regarding gender, age at diagnosis or EST, history of supraventricular tachycardia, presence of congenital heart disease or maximal heart rate. A cost comparison, utilizing the cost data: EST ($62.75) and EPS ($5,597) found EST to be a cost-saving approach in WPW patients. With 4 patients losing pre-excitation during EST, the cost saving of EST was $22,388 for this population of WPW patients. CONCLUSIONS: A frequency of 8% loss of pre-excitation was found in a pediatric sample that underwent EST. Additionally, EST was shown to be a cost-saving strategy in risk assessment of pediatric WPW patients.

Evaluation of stabilized blood cell products as candidate preparations for quality assessment programs for CD4 T-cell counting.

BACKGROUND: Exceptionally robust cell preparations are needed for quality assessment programs (QAPs) such as the International Program for Quality Assessment and Standardization for Immunological Measures (QASI) relevant to HIV/AIDS. A suitable product must withstand environmental stress related to transportation for a minimum of 6 days. The two objectives of this study are (1) to evaluate the performance of various commercial preparations with multicenter participation and (2) to evaluate the robustness of stabilized blood cell products. METHODS: Phase 1: The performance of stabilized blood cell products was evaluated in a multicenter QAP utilizing various staining procedures and flow cytometers. Absolute cell enumeration was achieved using single-platform T-cell subset methodology. Phase 2: The robustness of stabilized blood cell products was evaluated by monitoring T-cell subset values from samples stored at 4 degrees C, 22 degrees C, and 37 degrees C for up to 10 days. RESULTS: The largest interlaboratory variation in both absolute and relative T-cell values was 16% in samples with CD4 levels > or =400 cells per microliter and 21% in samples with CD4 levels <400 cells per microliter. Six preparations retained their phenotypic expression for 7 days at 4 degrees C and 22 degrees C. However, only two preparations remained stable for 4 days at 37 degrees C. CONCLUSION: Some stabilized cell preparations are more robust and therefore more suitable for quality assessment purposes.

Impact of the international program for Quality Assessment and Standardization for Immunological Measures Relevant to HIV/AIDS: QASI.

Measurements of CD4 T-cell levels are essential for the assessment of human immunodeficiency virus (HIV) disease course, clinical staging, epidemiological studies, and decisions regarding prophylactic therapies against opportunistic infection. Until now, only in the industrialized countries was T-cell subset monitoring considered a practical option to assess disease progression. The Quality Assessment and Standardization for Immunological Measures Relevant to HIV/AIDS (QASI) program was established in 1997 to meet performance assessment for immunophenotyping laboratories in countries where such service is not available. The QASI program is provided at no cost to any laboratory in a resource-poor setting that wishes to participate. This report describes the beneficial impact of participation in the QASI program. Carefully selected commercial stabilized whole blood preparations were sent regularly to participating laboratories. Participants reported the T-cell subset values they obtained by flow cytometry. Once the aggregate mean values for the T-cell subsets were established for the shipment, a comprehensive and confidential report was sent to each laboratory. The results from five consecutive shipments were analyzed. The coefficient of variation decreased from 7.2% to 4.7% and from 14.2% to 8.8% for percent and absolute CD4 T-cell counts, respectively. With the implementation of the QASI program using commercial stabilized whole blood specimens, it is possible to reduce interlaboratory error. This study illustrates that a quality assessment program can improve the overall performance of laboratories. Reducing interlaboratory variation can enhance significantly the effectiveness of multicenter HIV vaccine or drug trial evaluation.