Rectal Cancer and Radiation in Colitis.

Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. When IBD patients develop a rectal cancer, this should be treated with the same oncological principles and guidelines as the general population. Rectal cancer treatment includes surgery, chemotherapy, and radiation therapy (RT). Many IBD patients will require a total proctocolectomy with an ileal-pouch anal anastomosis (IPAA) and others, restoration of intestinal continuity may not be feasible or advisable. The literature is scarce regarding outcomes of IPAA after RT. In the present review, we will summarize the evidence regarding RT toxicity in IBD patients and review surgical strategies and outcomes of IPAA after RT.

Segmental versus extended colectomy for tumours of the transverse colon: a systematic review and meta-analysis.

AIM: There is no consensus on the appropriate extent of oncological resection for tumours of the transverse colon. Concerns regarding tumour factors such as pattern of lymph node spread and technical factors such as anastomotic perfusion lead to a variety of procedures being performed. METHODS: A comprehensive search for published studies examining outcomes following segmental versus extended colectomy for transverse colon tumours was performed adhering to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Random effects methods were used to combine data. RESULTS: Seven comparative series examining outcomes in 3395 patients were identified. Segmental colectomy results in shorter operating times (mean difference 15.80 min, 95% CI -20.98 to -10.62, P < 0.001) and less ileus (OR 0.52, 95% CI 0.33-0.81, P = 0.004). There was no difference in length of hospital stay (mean difference 1.53 days, 95% CI -3.79 to 0.73, P = 0.18). Extended colectomy results in a lower rate of anastomotic leak (OR 0.62, 95% CI 0.40-0.97, P = 0.04). There are fewer nodes retrieved in segmental colectomy (mean difference 7.60 nodes, 95% CI -9.60 to -5.61, P < 0.001) but no difference in disease recurrence (OR 0.88, 95% CI 0.59-1.34, P = 0.56) or overall survival (OR 0.98, 95% CI 0.68-1.4, P = 0.9). CONCLUSIONS: Available data are limited due to a lack of randomized controlled trials. However, based on current evidence, segmental resection for transverse colon tumours is associated with less ileus but lower lymph node yields and higher anastomotic leak rates. Length of stay is similar. Oncological outcomes are equivalent.

Effectiveness of a nurse-delivered (FOCUS+) and a web-based (iFOCUS) psychoeducational intervention for people with advanced cancer and their family caregivers (DIAdIC): study protocol for an international randomized controlled trial.

BACKGROUND: Worldwide, millions of people with advanced cancer and their family caregivers are experiencing physical and psychological distress. Psychosocial support and education can reduce distress and prevent avoidable healthcare resource use. To date, we lack knowledge from large-scale studies on which interventions generate positive outcomes for people with cancer and their informal caregivers' quality of life. This protocol describes the DIAdIC study that will evaluate the effectiveness of two psychosocial and educational interventions aimed at improving patient-family caregiver dyads' emotional functioning and self-efficacy. METHODS: We will conduct an international multicenter three-arm randomized controlled trial in Belgium, Denmark, Ireland, Italy, The Netherlands, and the United Kingdom. In each country, 156 dyads (936 in total) of people with advanced cancer and their family caregiver will be randomized to one of the study arms: 1) a nurse-led face-to-face intervention (FOCUS+), 2) a web-based intervention (iFOCUS) or 3) a control group (care as usual). The two interventions offer tailored psychoeducational support for patient-family caregiver dyads. The nurse-led face-to-face intervention consists of two home visits and one online video session and the web-based intervention is completed independently by the patient-family caregiver dyad in four online sessions. The interventions are based on the FOCUS intervention, developed in the USA, that addresses five core components: family involvement, optimistic outlook, coping effectiveness, uncertainty reduction, and symptom management. The FOCUS intervention will be adapted to the European context. The primary outcomes are emotional functioning and self-efficacy of the patient and the family caregiver, respectively. The secondary outcomes are quality of life, benefits of illness, coping, dyadic communication, and ways of giving support of the patient and family caregiver. DISCUSSION: DIAdIC aims to develop cost-effective interventions that integrate principles of early palliative care into standard care. The cross-country setup in six European countries allows for comparison of effectiveness of the interventions in different healthcare systems across Europe. By focusing on empowerment of the person with cancer and their family caregiver, the results of this RCT can contribute to the search for cost-effective novel interventions that can relieve constraints on professional healthcare. TRIAL REGISTRATION: Registration on ClinicalTrials.gov on 12/11/2020, identifier NCT04626349 . DATE AND VERSION IDENTIFIER: 20211209_DIAdIC_Protocol_Article.

The Evidence-based Practice for Improving Quality method has greater impact on improvement of outcomes than dissemination of practice change guidelines and quality improvement training in neonatal intensive care units.

OBJECTIVES: To determine whether outcome improvements achieved by neonatal intensive care units (NICUs) in the Evidence-based Practice for Improving Quality (EPIQ) trial could be reproduced in other NICUs by providing quality improvement (QI) training and practice change guidelines developed during the EPIQ trial; and to examine whether the results of the EPIQ trial were sustained. METHODS: The present prospective before-after study included 5812 infants born at ≤32 weeks' gestation and admitted to 19 level 3 NICUs in the Canadian Neonatal Network between October 1, 2005 and December 31, 2007. During a three-month baseline period, multi-disciplinary teams received general training in QI techniques at a two-day workshop, and practice change guidelines targeting nosocomial infection (NI) and bronchopulmonary dysplasia (BPD) developed during the EPIQ trial were provided to all participants. Outcome data collected during the intervention period were compared with data from the baseline period and reported quarterly. RESULTS: In NICUs that had not previously participated in the EPIQ trial (non-EPIQ NICUs), there were no significant changes in the incidence trends of NI or BPD. However, within NICUs that had previously participated in the EPIQ trial (EPIQ NICUs) there was a continued reduction in the incidence trend of NI and BPD among EPIQ NICUs randomized during the trial to reduce NI and BPD, respectively. CONCLUSIONS: Providing NICUs with QI training and practice change guidelines developed during a successful QI initiative in other units is not effective. The authors speculate that successful practice change involves organizational culture and behaviour change, and should be driven by context-specific evidence.

OBJECTIFS: Déterminer s'il est possible de reproduire, dans d'autres unités de soins intensifs néonatals (USIN), l'amélioration des résultats obtenue dans certaines USIN lors de l'essai EPIQ (acronyme anglais de pratiques fondées sur des données probantes pour l'amélioration de la qualité) grâce à une formation sur l'amélioration de la qualité (AQ) et à des directives sur les changements de pratiques élaborées pendant l'essai EPIQ. Examiner si les résultats de l'essai EPIQ se maintiennent. MÉTHODOLOGIE: La présente étude prospective avant-après portait sur 5 812 nourrissons nés à 32 semaines d'âge gestationnel ou moins et hospitalisés dans 19 USIN de niveau 3 du Réseau néonatal canadien entre le 1er octobre 2005 et le 31 décembre 2007. Pendant une période de référence de trois mois, des équipes multidisciplinaires ont reçu une formation générale sur les techniques d'AQ lors d'un atelier de deux jours. De plus, tous les participants ont reçu des directives sur les changements de pratiques ciblant les infections nosocomiales (IN) et la dysplasie bronchopulmonaire (DBP) élaborées pendant l'essai EPIQ. Les chercheurs ont comparé les données sur les résultats, colligées pendant la période d'intervention, aux données de la période de référence regroupées par trimestre. RÉSULTATS: Dans les USIN qui n'avaient pas participé à l'essai EPIQ auparavant (les USIN non EPIQ), on n'a pas remarqué de changement important aux tendances d'IN ou de DBP. Cependant, au sein des USIN qui avaient participé à l'essai EPIQ (les USIN EPIQ) et qui avaient été choisies au hasard pour réduire les IN et la DBP, respectivement, on constatait une réduction continue des tendances d'IN et de DBP. CONCLUSIONS: Il n'est pas efficace de fournir aux USIN une formation sur l'AQ et des directives sur les changements de pratiques élaborées dans le cadre d'une initiative réussie d'AQ menée dans d'autres USIN. Les auteurs postulent que pour être efficaces, les changements de pratiques doivent susciter des modifications à la culture organisationnelle et aux comportements et reposer sur des données probantes contextuelles.

Variations in transport outcomes of outborn infants among Canadian neonatal intensive care units.

BACKGROUND: Outborn infants born at community hospitals and transported to tertiary neonatal intensive care units (NICUs) for treatment account for 20% of all tertiary NICU admissions in Canada. Little is known about variations in their outcomes. The Transport Risk Index of Physiologic Stability (TRIPS) is a validated score of neonatal physiological status that can identify differences between transport teams' outcomes. OBJECTIVE: To examine regional variations in outcomes among outborn infants transported to Canadian tertiary NICUs using TRIPS. DESIGN AND METHODS: Transport teams prospectively collected data for all outborn infants admitted to 25 Canadian NICUs during 2006 to 2007. Singleton outborn infants ≥ 32 weeks' gestation admitted to NICUs for at least 24 hours who died or who were transferred to another NICU within 24 hours were examined for overall incidence of mortality, major morbidity, and change in TRIPS score. RESULTS: Complete transport data were available for 2313 (72.9%) of 3193 eligible infants. There were significant variations in interhospital and interprovincial outcomes. Factors significantly affecting change in TRIPS score were gender, pretransport TRIPS score, composition of transport team and distance traveled. CONCLUSION: Significant variation exists in transport outcomes in Canada. Further investigation is required to optimize infant transport systems, processes, and clinical care.

Painful to Discuss: The Intersection of Chronic Pain, Mental Health, and Analgesic Use among People with HIV.

Objective: This retrospective chart review study aims to identify patients in an HIV clinical setting in an area of high HIV prevalence in Atlanta, Georgia, USA who have chronic pain, analgesic prescriptions, and/or mental health diagnoses. Design: People living with HIV (PLWH) are at higher risk for experiencing trauma, mental health conditions, and chronic pain than their HIV-negative counterparts. This study was designed to evaluate the intersection of these factors within an urban HIV clinic. Methods: Retrospective chart review study. Results: Of the adult patients enrolled at an HIV clinic in Atlanta, Georgia USA between 2011-2022 (n=15,970), 93.7% were prescribed analgesics, 40.5% had documented pain diagnoses, and 23.5% had documented mental health diagnoses. Additionally, 14.3% of all enrolled patients had all three factors concurrently. Conclusions: The complexity of HIV, chronic pain, mental health challenges, and analgesic use demand a patient-centered, collaborative approach including a multidisciplinary care team. Seeing persistent pain among PLWH with a trauma-informed approach to care within the lens of co-occurring mental health diagnoses will allow us to better understand, treat, and sustain patients in life-saving HIV care.

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study.

BACKGROUND: Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada. METHODS: We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events. RESULTS: A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65-5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08-9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0-3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2-0.9). INTERPRETATION: More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.

Normal adrenal function in an infant following a pregnancy complicated by maternal adrenal cortical carcinoma and mitotane exposure.

Maternal adrenal cortical carcinoma in pregnancy is rare. We report a case of an infant born to a mother with a history of adrenal cortical carcinoma. The pregnancy was complicated by fetal exposure to mitotane and dexamethasone. Despite the potential teratogenic exposures, there was no evidence of adrenal dysfunction in the infant. Growth and development at 12 months of age are normal and prognosis appears favorable. The long-term impact of fetal exposure to mitotane and glucocorticoid requires further investigation.

Reflections on knowledge translation in Canadian NICUs using the EPIQ method.

The Canadian Neonatal Network conducted a trial of Evidence-Based Practice for Improving Quality (EPIQ) between 2002 and 2005. Improved neonatal intensive care unit (NICU) outcomes established credibility for quality improvement. We surveyed team members and physician leaders to examine critical success factors and barriers to improvement during EPIQ. Respondents agreed that EPIQ had a high utility, was effectively implemented and was a major learning opportunity. The collaborative nature of the project was key to success. Respondents identified the need for additional training and resources in quality improvement. Better communication between clinicians and senior leaders is required to support quality improvement in NICUs.

Assessment of a Contralateral Esophagus-Sparing Technique in Locally Advanced Lung Cancer Treated With High-Dose Chemoradiation: A Phase 1 Nonrandomized Clinical Trial.

IMPORTANCE: Severe acute esophagitis occurs in up to 20% of patients with locally advanced lung cancer treated with chemoradiation therapy to at least 60 Gy once daily and represents a dose-limiting toxic event associated with poor outcomes. OBJECTIVE: To assess whether formalized sparing of the contralateral esophagus (CE) is associated with reduced risk of severe acute esophagitis. DESIGN, SETTING, AND PARTICIPANTS: This single-center phase 1 nonrandomized clinical trial assessing an empirical CE-sparing technique enrolled patients from July 2015 to January 2019. In total, 27 patients with locally advanced non-small cell lung carcinoma (with or without solitary brain metastasis) or limited-stage small cell lung carcinoma with gross tumor within 1 cm of the esophagus were eligible. INTERVENTIONS: Intensity-modulated radiation therapy to 70 Gy at 2 Gy/fraction concurrent with standard chemotherapy with or without adjuvant durvalumab. The esophageal wall contralateral to gross tumor was contoured as an avoidance structure to guide a steep dose falloff gradient. Target coverage was prioritized over CE sparing, and 99% of internal and planning target volumes had to be covered by 70 Gy and at least 63 Gy, respectively. MAIN OUTCOMES AND MEASURES: The primary end point was the rate of at least grade 3 acute esophagitis as assessed by Common Terminology Criteria for Adverse Events, version 4. RESULTS: Of 27 patients enrolled, 25 completed chemoradiation therapy. Nineteen patients had non-small cell lung carcinoma, and 6 had small cell lung carcinoma. The median age at diagnosis was 67 years (range, 51-81 years), and 15 patients (60%) were men. Thirteen patients (52%) had stage IIIA cancer, 10 (40%) had stage IIIB cancer, and 2 (8%) had stage IV cancer. The median CE maximum dose was 66 Gy (range, 44-71 Gy); the median volume of CE receiving at least 55 Gy was 1.4 cm3 (range, 0-5.3 cm3), and the median volume of CE receiving at least 45 Gy was 2.7 cm3 (range, 0-9.2 cm3). The median combined percentage of lung receiving at least 20 Gy was 25% (range, 11%-37%). The median follow-up was 33.3 months (range, 11.1-52.2 months). Among the 20 patients who had treatment breaks of 0 to 3 days and were thus evaluable for the primary end point, the rate of at least grade 3 esophagitis was 0%. Other toxic events observed among all 25 patients included 7 (28%) with grade 2 esophagitis, 3 (12%) with at least grade 2 pneumonitis (including 1 with grade 5), and 2 (8%) with at least grade 3 cardiac toxic event (including 1 with grade 5). There was no isolated local tumor failure. The 2-year progression-free survival rate was 57% (95% CI, 33%-75%), and the 2-year overall survival rate was 67% (95% CI, 45%-82%). CONCLUSIONS AND RELEVANCE: This phase 1 nonrandomized clinical trial found that the CE-sparing technique was associated with reduced risk of esophagitis among patients treated uniformly with chemoradiation therapy (to 70 Gy), with no grade 3 or higher esophagitis despite tumor within 1 cm of the esophagus. This technique may be translated into clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02394548.

The Role of Gut Microbiota and Environmental Factors in Type 1 Diabetes Pathogenesis.

Type 1 Diabetes (T1D) is regarded as an autoimmune disease characterized by insulin deficiency resulting from destruction of pancreatic ß-cells. The incidence rates of T1D have increased worldwide. Over the past decades, progress has been made in understanding the complexity of the immune response and its role in T1D pathogenesis, however, the trigger of T1D autoimmunity remains unclear. The increasing incidence rates, immigrant studies, and twin studies suggest that environmental factors play an important role and the trigger cannot simply be explained by genetic predisposition. Several research initiatives have identified environmental factors that potentially contribute to the onset of T1D autoimmunity and the progression of disease in children/young adults. More recently, the interplay between gut microbiota and the immune system has been implicated as an important factor in T1D pathogenesis. Although results often vary between studies, broad compositional and diversity patterns have emerged from both longitudinal and cross-sectional human studies. T1D patients have a less diverse gut microbiota, an increased prevalence of Bacteriodetes taxa and an aberrant metabolomic profile compared to healthy controls. In this comprehensive review, we present the data obtained from both animal and human studies focusing on the large longitudinal human studies. These studies are particularly valuable in elucidating the environmental factors that lead to aberrant gut microbiota composition and potentially contribute to T1D. We also discuss how environmental factors, such as birth mode, diet, and antibiotic use modulate gut microbiota and how this potentially contributes to T1D. In the final section, we focus on existing recent literature on microbiota-produced metabolites, proteins, and gut virome function as potential protectants or triggers of T1D onset. Overall, current results indicate that higher levels of diversity along with the presence of beneficial microbes and the resulting microbial-produced metabolites can act as protectors against T1D onset. However, the specifics of the interplay between host and microbes are yet to be discovered.

Improving the quality of care for infants: a cluster randomized controlled trial.

BACKGROUND: We developed and tested a new method, called the Evidence-based Practice for Improving Quality method, for continuous quality improvement. METHODS: We used cluster randomization to assign 6 neonatal intensive care units (ICUs) to reduce nosocomial infection (infection group) and 6 ICUs to reduce bronchopulmonary dysplasia (pulmonary group). We included all infants born at 32 or fewer weeks gestation. We collected baseline data for 1 year. Practice change interventions were implemented using rapid-change cycles for 2 years. RESULTS: The difference in incidence trends (slopes of trend lines) between the ICUs in the infection and pulmonary groups was - 0.0020 (95% confidence interval [CI] - 0.0007 to 0.0004) for nosocomial infection and - 0.0006 (95% CI - 0.0011 to - 0.0001) for bronchopulmonary dysplasia. INTERPRETATION: The results suggest that the Evidence-based Practice for Improving Quality method reduced bronchopulmonary dysplasia in the neonatal ICU and that it may reduce nosocomial infection.

Are We Cutting Enough? A Five-Year Audit of Melanoma Excision Margins in the South East of Ireland.

AIM: Malignant melanoma is the fifth commonest invasive cancer in Ireland. The British Association of Dermatology (BAD) guidelines are currently the recognized standard for melanoma related surgery. The aim was to examine adherence to BAD guidelines and establish contributing factors resulting in non-adherence to guidelines in a group of melanoma patients in the South East Region of Ireland. METHODS: A retrospective review of a prospectively maintained melanoma registry of all patients undergoing surgery in the South East Region of Ireland from January 2011 to 2016 was performed. Data were analyzed using SPSS statistical software. Univariate analysis using logistic regression was performed to examine factors associated with not meeting the BAD margin excision guidelines Data with a p < 0.05 was analyzed using a multivariate logistic regression model. RESULTS: 459 patients underwent surgery for invasive cutaneous melanoma. 314 (68.4%) surgeries had excision margins adequately recorded and of these 234(74.5%) fulfilled the BAD guidelines. 267(58.2%) patients (2011-2016 inclusive) qualified for sentinel lymph node biopsy (SNLB) with a cancer staging of pT1b or higher. Of these patients 100(37%) agreed to proceed to a SNLB following informed discussion. 33 had a positive sentinel node. On multivariate analysis inadequate margins were independently associated with tumor thickness 2.01-4.00 mm (p = 0.0001) and >4.00 mm (p = 0.0001) and head and neck location (p < 0.0001). CONCLUSIONS: Adherence to BAD guidelines in the South East is good but requires optimization since centralization of melanoma treatment in 2013 to a single specialized center. It is important that Clinicians are fully aware of the implications of not achieving adequate excision margins in surgery. Improvements in melanoma data management is needed to fully evaluate current practices in Ireland.

Retrospective economic evaluation of a controlled trial of indomethacin prophylaxis for patent ductus arteriosus in premature infants.

OBJECTIVE: To determine the incremental cost-effectiveness of indomethacin prophylaxis in extremely low birth weight infants enrolled in the Trial of Indomethacin Prophylaxis in Preterms (TIPP). STUDY DESIGN: Participants in this economic evaluation were 428 infants enrolled at 9 Canadian TIPP centres. The study took a third-party payer perspective. Prior to the analysis of clinical trial data, direct medical costs were derived from chart review of 89 items of resource utilization, for each day from admission to hospital discharge. Unit costs for each resource were obtained from a provincially standardized cost-accounting system. Incremental cost-effectiveness analysis was performed, with estimation of cost-effectiveness acceptability curves through non-parametric bootstrapping. RESULTS: The mean (SD) cost was $68,279 (40,317) for the placebo group and $69,629 (37,989) for the indomethacin group. Indomethacin prophylaxis cost an additional $67,500 per death or impairment averted. However, the precision of this estimate was low, such that the probability that the estimate was lower than $300,000 per death or impairment averted was only 61%. The results were similar when surgical costs were assumed to be 500% of those measured in the trial. CONCLUSIONS: This study does not provide an economic rationale for the use of indomethacin prophylaxis in ELBW infants.

Five years of learning from analysis of clinical occurrences in pediatric care using the London Protocol.

A Protocol for the Investigation of Clinical Incidents (1999) was piloted on a Winnipeg high-risk neonatal service in 2001, and was subsequently adopted as the investigative tool of choice at the Winnipeg Regional Health Authority (WRHA). The paper describes the pilot and subsequent experience with the updated London Protocol (2004) in the WRHA Child Health Program. Themes include: tightly coupled systems; multiplicity of contributory factors; medication safety; predominance of "near misses"; authority gradient; professional accountability; partnerships; and implementation challenges. The London Protocol is an invaluable tool for review of critical occurrences and near misses. To maximize impact on patient safety, healthcare organizations must involve partners and develop expertise in human factors and change management.

Actuarial survival of a large Canadian cohort of preterm infants.

BACKGROUND: The increased survival of preterm and very low birth weight infants in recent years has been well documented but continued surveillance is required in order to monitor the effects of new therapeutic interventions. Gestation and birth weight specific survival rates most accurately reflect the outcome of perinatal care. Our aims were to determine survival to discharge for a large Canadian cohort of preterm infants admitted to the neonatal intensive care unit (NICU), and to examine the effect of gender on survival and the effect of increasing postnatal age on predicted survival. METHODS: Outcomes for all 19,507 infants admitted to 17 NICUs throughout Canada between January 1996 and October 1997 were collected prospectively. Babies with congenital anomalies were excluded from the study population. Gestation and birth weight specific survival for all infants with birth weight < 1,500 g (n = 3419) or gestation < or = 30 weeks (n = 3119) were recorded. Actuarial survival curves were constructed to show changes in expected survival with increasing postnatal age. RESULTS: Survival to discharge at 24 weeks gestation was 54%, compared to 82% at 26 weeks and 95% at 30 weeks. In infants with birth weights 600-699, survival to discharge was 62%, compared to 79% at 700-799 g and 96% at 1,000-1,099 g. In infants born at 24 weeks gestational age, survival was higher in females but there were no significant gender differences above 24 weeks gestation. Actuarial analysis showed that risk of death was highest in the first 5 days. For infants born at 24 weeks gestation, estimated survival probability to 48 hours, 7 days and 4 weeks were 88 (CI 84, 92)%, 70 (CI 64, 76)% and 60 (CI 53, 66)% respectively. For smaller birth weights, female survival probabilities were higher than males for the first 40 days of life. CONCLUSION: Actuarial analysis provides useful information when counseling parents and highlights the importance of frequently revising the prediction for long term survival particularly after the first few days of life.

The Association of Organizational Culture and Quality Improvement Implementation With Neonatal Outcomes in the NICU.

INTRODUCTION: Studies of adult patient populations suggest that organizational culture is associated with quality improvement (QI) implementation, as well as patient outcomes. However, very little research on organizational culture has been performed in neonatal patient populations. METHOD: This combined cross-sectional survey and retrospective cohort study assessed employee perceptions of organizational culture and QI implementation within 18 Canadian neonatal intensive care units. The associations between these data and neonatal outcomes in extremely preterm infants (born at < 29 weeks' gestation) were then assessed using multivariable analyses. RESULTS: Perceptions of unit culture and QI implementation varied according to occupation and age. Higher hierarchical culture was associated with increased survival without major morbidities (odds ratio, 1.04; 95% confidence interval, 1.01-1.06), as were higher QI implementation scores (odds ratio range, 1.20-1.36 by culture type). DISCUSSION: Our data suggest that organizational culture, particularly hierarchical culture, and level of QI implementation may play a role in neonatal outcomes.

Role for purinergic receptors in memory processing in young chicks.

The current study used a single trial bead discrimination task for the young chick to ascertain if inhibitors of P2 purinergic receptors would impair memory retention. Suramin and PPADS provided similar retention profiles. Loss of memory retention was evident by 60 min post-training. Both drugs caused persistent memory loss which was still evident 24h post-training. These findings suggest that P2 receptors have a role in memory processing.

Description of the development and validation of the Canadian Paediatric Trigger Tool.

OBJECTIVE: To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT). METHODS: Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger. RESULTS: Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT. CONCLUSIONS: The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.