Standardization and quality control of Doppler and fetal biometric ultrasound measurements in low-income setting.

OBJECTIVE: The aim of this study was to determine the quality of fetal biometry and pulsed-wave Doppler ultrasound measurements in a prospective cohort study in Uganda. METHODS: This was an ancillary study of the Ending Preventable Stillbirths by Improving Diagnosis of Babies at Risk (EPID) project, in which women enroled in early pregnancy underwent Doppler and fetal biometric assessment at 32-40 weeks of gestation. Sonographers undertook 6 weeks of training followed by onsite refresher training and audit exercises. A total of 125 images for each of the umbilical artery (UA), fetal middle cerebral artery (MCA), left and right uterine arteries (UtA), head circumference (HC), abdominal circumference (AC) and femur length (FL) were selected randomly from the EPID study database and evaluated independently by two experts in a blinded fashion using objective scoring criteria. Inter-rater agreement was assessed using modified Fleiss' kappa for nominal variables and systematic errors were explored using quantile-quantile (Q-Q) plots. RESULTS: For Doppler measurements, 96.8% of the UA images, 84.8% of the MCA images and 93.6% of the right UtA images were classified as of acceptable quality by both reviewers. For fetal biometry, 96.0% of the HC images, 96.0% of the AC images and 88.0% of the FL images were considered acceptable by both reviewers. The kappa values for inter-rater reliability of quality assessment were 0.94 (95% CI, 0.87-0.99) for the UA, 0.71 (95% CI, 0.58-0.82) for the MCA, 0.87 (95% CI, 0.78-0.95) for the right UtA, 0.94 (95% CI, 0.87-0.98) for the HC, 0.93 (95% CI, 0.87-0.98) for the AC and 0.78 (95% CI, 0.66-0.88) for the FL measurements. The Q-Q plots indicated no influence of systematic bias in the measurements. CONCLUSIONS: Training local healthcare providers to perform Doppler ultrasound, and implementing quality control systems and audits using objective scoring tools in clinical and research settings, is feasible in low- and middle-income countries. Although we did not assess the impact of in-service retraining offered to practitioners deviating from prescribed standards, such interventions should enhance the quality of ultrasound measurements and should be investigated in future studies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Constructing evidence-based clinical intrapartum care algorithms for decision-support tools.

AIM: To describe standardised iterative methods used by a multidisciplinary group to develop evidence-based clinical intrapartum care algorithms for the management of uneventful and complicated labours. POPULATION: Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility. SETTING: Health facilities in low- and middle-income countries. SEARCH STRATEGY: Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google. CASE SCENARIOS: Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes. CONCLUSIONS: Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence-based, up to date, paper-based or digital reminders and decision-support tools. The algorithms need to be field tested and may need to be adapted to specific contexts. TWEETABLE ABSTRACT: Evidence-based intrapartum care clinical algorithms for a safe and positive childbirth experience.

A mixed-methods evaluation of hepatitis B knowledge, attitudes, and practices among migrant women in Thailand.

BACKGROUND: Globally 90 % of transmission of Hepatitis B virus (HBV) is from mother-to child and occurs predominantly in resource limited countries where the prevalence of HBV is high. Transmission could be interrupted by timely vaccinations but coverage remains problematic in these areas. Low knowledge or awareness of HBV may play a part in low vaccination coverage. This study examines the provision of antenatal care counselling with a focus on HBV in two different regions of northern Thailand, Sarapee Hospital (SH), Chiang Mai, and Shoklo Malaria Research Unit (SMRU), Tak Province. METHODS: A mixed-methods sequential explanatory study design was used to evaluate antenatal services for migrants. Cross-sectional knowledge, attitude and practice (KAP) surveys were conducted immediately after counselling at first ANC contact, at 3-6 months after first ANC contact and at delivery. Surveys provided quantitative data, and qualitative methods included observations, focus group discussions (FGD) and in-depth interviews (IDI); analysed thematically to explore concepts of knowledge and understanding, attitude and practice of pregnant women and providers. RESULTS: Between September-2019 and May-2020, 757 women participated to KAP surveys, and 31 observations of counselling, 16 FGD and 9 IDI were conducted. KAP surveys showed in spite of low knowledge about HBV transmission, infection, or vaccination (correct response: SH 5.7 %, 9/157; SMRU 34.0 %, 204/600), most women (≥ 93 %, either site) understood they were screened for HBV and were willing to vaccinate infants for HBV. In explaining KAP survey results, qualitative analysis suggests counselling should: use the appropriate language; be tailored to the local health literacy level, provide only pertinent information, be repeated over the antenatal period; and attempt to ensure patient privacy (where possible). Programme effectiveness benefits from positive attitudes to screening and vaccinations and a high level of trust in the providers nevertheless participants provided good suggestions for improvements of the service. CONCLUSIONS: Limited knowledge of HBV among migrant women can be improved by counselling that emphasizes actionable knowledge such as vaccination schedule. Key improvements to the counselling process include training counsellors to conduct interactive counselling sessions in the woman's language, using appropriate visual aids and timely repetition over the course of the antenatal period.

The effect of automated oxygen control on clinical outcomes in preterm infants: a pre- and post-implementation cohort study.

Several studies demonstrated an increase in time spent within target range when automated oxygen control (AOC) is used. However the effect on clinical outcome remains unclear. We compared clinical outcomes of preterm infants born before and after implementation of AOC as standard of care. In a retrospective pre-post implementation cohort study of outcomes for infants of 24-29 weeks gestational age receiving respiratory support before (2012-2015) and after (2015-2018) implementation of AOC as standard of care were compared. Outcomes of interest were mortality and complications of prematurity, number of ventilation days, and length of stay in the Neonatal Intensive Care Unit (NICU). A total of 588 infants were included (293 pre- vs 295 in the post-implementation cohort), with similar gestational age (27.8 weeks pre- vs 27.6 weeks post-implementation), birth weight (1033 grams vs 1035 grams) and other baseline characteristics. Mortality and rate of prematurity complications were not different between the groups. Length of stay in NICU was not different, but duration of invasive ventilation was shorter in infants who received AOC (6.4 ± 10.1 vs 4.7 ± 8.3, p = 0.029).Conclusion: In this pre-post comparison, the implementation of AOC did not lead to a change in mortality or morbidity during admission. What is Known: • Prolonged and intermittent oxygen saturation deviations are associated with mortality and prematurity-related morbidities. • Automated oxygen controllers can increase the time spent within oxygen saturation target range. What is New: • Implementation of automated oxygen control as standard of care did not lead to a change in mortality or morbidity during admission. • In the period after implementation of automated oxygen control, there was a shift toward more non-invasive ventilation.

Tenofovir for prevention of mother to child transmission of hepatitis B in migrant women in a resource-limited setting on the Thailand-Myanmar border: a commentary on challenges of implementation.

BACKGROUND: The aim of this manuscript is to highlight challenges in the implementation of maternal tenofovir disoproxil fumarate (tenofovir) for prevention of mother to child transmission (PMTCT) of hepatitis B virus (HBV) in resource limited setting. Current preventive strategies in resource-limited settings fail mainly due to prohibitive costs of hepatitis B immunoglobulin (HBIG) and a high proportion of homebirths, meaning both HBIG and hepatitis B birth dose vaccine are not given. A new strategy for PMTCT without the necessity of HBIG, could be daily tenofovir commenced early in gestation. Implementation challenges to early tenofovir for PMTCT can provide insight to elimination strategies of HBV as the burden of disease is high in resource-limited settings. METHODS: Challenges encountered during implementation of a study of tenofovir for PMTCT before 20 weeks gestation in rural and resource-limited areas on the Thailand-Myanmar border were identified informally from trial study logbooks and formally from comments from patients and staff at monthly visits. ClinicalTrials.gov Identifier: NCT02995005. MAIN BODY: During implementation 171 pregnant women were hepatitis B surface antigen (HBsAg) positive by point of-care test over 19 months (May-2018 until Dec-2019). In this resource-limited setting where historically no clinic has provided tenofovir for PMTCT of HBV, information provided by staff resulted in a high uptake of study screening (95.5% (84/88) when offered to pregnant women. False positive point-of-care rapid tests hinder a test and treat policy for HBV and development of improved rapid tests that include HBeAg and/or HBV DNA would increase efficiency. Integrated care of HBV to antenatal care, transport assistance and local agreements to facilitate access, could increase healthcare at this critical stage of the life course. As safe storage of medication in households in resource-limited setting may not be ideal, interactive counseling about this must be a routine part of care. CONCLUSION: Despite challenges, results from the study to date suggest tenofovir can be offered to HBV-infected women in resource-limited settings before 20 weeks gestation with a high uptake of screening, high drug accountability and follow-up, with provision of transportation support. This commentary has highlighted practical implementation issues with suggestions for strategies that support the objective of PMTCT and the World Health Organization goal of HBV elimination by 2030.

High risk of long-term neurodevelopmental impairment in donor twins with spontaneous twin anemia-polycythemia sequence.

OBJECTIVES: To evaluate the long-term neurodevelopmental and behavioral outcomes in surviving infants of pregnancies with spontaneous twin anemia-polycythemia sequence (TAPS), to compare outcome between donors and recipients, and to investigate potential risk factors for neurodevelopmental impairment (NDI). METHODS: This was a retrospective study of a consecutive cohort of spontaneous-TAPS survivors delivered between 2005 and 2017 at the Leiden University Medical Center, The Netherlands. Neurological, motor, cognitive and behavioral development were assessed at a median age of 4 years. The primary outcome was NDI, which was a composite outcome of cerebral palsy, deafness, blindness and motor and/or cognitive delay. NDI was subdivided into two grades of severity: mild-to-moderate and severe NDI. Outcome was compared between surviving donor and recipient twins. Logistic regression analysis was used to assess risk factors for NDI. RESULTS: Forty-nine twin pregnancies complicated by spontaneous TAPS were eligible for inclusion. The perinatal survival rate was 83% (81/98) of twins. Neurodevelopmental assessment was performed in 91% (74/81) of surviving twins. NDI occurred in 30% (22/74) of TAPS survivors, and was found more often in donors (44%; 15/34) than in recipients (18%; 7/40) (odds ratio (OR), 4.1; 95% CI, 1.8-9.1; P = 0.001). Severe NDI was detected in 9% (7/74) of survivors and was higher in donors compared with recipients (18% (6/34) vs 3% (1/40)), although the difference did not reach statistical significance; P = 0.056). Donors demonstrated lower cognitive scores compared with recipients (P = 0.011). Bilateral deafness was identified in 15% (5/34) of donors compared with 0% (0/40) of recipients (P = 0.056). Parental concern regarding development was reported more often for donor than for recipient twins (P = 0.001). On multivariate analysis, independent risk factors for NDI were gestational age at delivery (OR, 0.7; 95% CI, 0.5-0.9; P = 0.003) and severe anemia (OR, 6.4; 95% CI, 2.4-17.0; P < 0.001). CONCLUSION: Surviving donor twins of pregnancies complicated by spontaneous TAPS have four-fold higher odds of NDI compared with recipient cotwins, are at increased risk of cognitive delay and have a high rate of deafness. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Quality of care assessment for people with multimorbidity.

Multimorbidity, the simultaneous presence of multiple health conditions in an individual, is an increasingly common phenomenon globally. The systematic assessment of the quality of care delivered to people with multimorbidity will be key to informing the organization of services for meeting their complex needs. Yet, current assessments tend to focus on single conditions and do not capture the complex processes that are required for providing care for people with multimorbidity. We conducted a scoping review on quality of care and multimorbidity in selected databases in June 2018 and identified 87 documents as eligible for review, predominantly original research and reviews from North America, Europe and Australasia and mostly frequently related to primary care settings. We synthesized data qualitatively in terms of perceived challenges, evidence and proposed metrics. Findings reveal that the association between quality of care and multimorbidity is complex and depends on the conditions involved (quality appears to be higher for those with concordant conditions, and lower in the presence of discordant conditions) and the approach used for measuring quality (quality appears to be higher in people with multimorbidity when measured using condition/drug-specific process or intermediate outcome indicators, and worse when using patient-centred reports of experiences of care). People with discordant multimorbidity may be disadvantaged by current approaches to quality assessment, particularly when they are linked to financial incentives. A better understanding of models of care that best meet the needs of this group is needed for developing appropriate quality assessment frameworks. Capturing patient preferences and values and incorporate patients' voices in the form of patient-reported experiences and outcomes of care will be critical towards the achievement of high-performing health systems that are responsive to the needs of people with multimorbidity.

Retrospective Review of Documentation Practices of Hepatitis B Immunoglobulin, Birth Dose, and Vaccination at the Hospital of Birth, in Thai Nationals and Migrants in Northern Thailand.

BACKGROUND: Vaccination remains the mainstay of prevention of hepatitis B virus (HBV) including birth dose and hepatitis B immunoglobulins (HBIGs). National estimates of vaccination coverage exclude migrants. The objective of this study is to investigate documentation practices of HBV-related infant vaccinations in Northern Thailand including migrants. METHODS: This is a retrospective review of hospital records of women who birthed infants in 2015 at Maharaj Nakorn Hospital, Chiang Mai (CM) or on the Thailand-Myanmar border, Tak. RESULTS: Of 2522 women, 987 were from CM (861 Thai nationals, 126 migrants) and 1535 were from Tak (651 Thai residence and 884 Myanmar residence). In CM, documentation for the birth dose vaccine (999 of 999, 100%) and HBIG was complete. In Tak, documentation was 1441 of 1549 (93%) for birth dose and 26 of 34 (76.5%) for HBIG, with missed opportunities including home delivery, delay in obtaining hepatitis B e-antigen status, and limitations of the records. Expanded Program of Immunization (EPI) documentation of 3 follow-up vaccinations dwindled with subsequent doses and distance, and complete documentation of 3 HBV EPI vaccines at the hospital of birth was low, 41.5% (1056 of 2547), but equitable for Thai or migrant status. CONCLUSIONS: This review provides strong support for excellent documentation of HBIG and birth dose vaccination in urban and rural settings, and in migrants, consistent with Thailand's vaccination policy and practice. Documentation of the 3 HBV EPI at the hospital of birth decreases with sequential doses, especially in families further away. Innovative data linkage is required to prove coverage and identify gaps.

Population Pharmacokinetics of Amoxicillin in Term Neonates Undergoing Moderate Hypothermia.

The pharmacokinetics (PK) of amoxicillin in asphyxiated newborns undergoing moderate hypothermia were quantified using prospective data (N = 125). The population PK was described by a 2-compartment model with a priori birthweight (BW) based allometric scaling. Significant correlations were observed between clearance (Cl) and postnatal age (PNA), gestational age (GA), body temperature (TEMP), and urine output (UO). For a typical patient with GA 40 weeks, BW 3,000 g, 2 days PNA (i.e., TEMP 33.5°C), and normal UO, Cl was 0.26 L/h (interindividual variability (IIV) 41.9%) and volume of distribution of the central compartment was 0.34 L/kg (IIV of 114.6%). For this patient, Cl increased to 0.41 L/h at PNA 5 days and TEMP 37.0°C. The respective contributions of both covariates were 23% and 27%. Based on Monte Carlo simulations we recommend 50 and 75 mg/kg/24h amoxicillin in three doses for patients with GA 36-37 and 38-42 weeks, respectively.

Learning Curve Characteristics for Caesarean Section Among Associate Clinicians: A Prospective Study from Sierra Leone.

BACKGROUND: In response to the high maternal mortality ratio, Sierra Leone has adopted an associate clinician postgraduate surgical task-sharing training programme. Little is known about learning curve characteristics for caesarean sections among associate clinicians. The aim of this study is to evaluate the number of caesarean sections needed to be performed by associate clinicians until there is no further significant reduction in operation time. METHODS: This prospective study evaluates the first 50 caesarean sections performed by trainees between January 2011 and June 2016. Primary outcome was total operating time in minutes (incision to suturing time). Secondary outcomes were length of hospital stay, surgical site infections, estimated operative bloodloss and in-hospital postoperative mortality. RESULTS: A total of 1174 caesarean sections performed by 24 trainees were analysed. Total operation time significantly reduced during the first 15 operations from mean (SD) operation time 72 (27)-51 (18) min after 15 procedures (p < 0.001). Estimated bloodloss did not significantly vary among the first 50 caesarean sections. Surgical site infections were reported in 3.7% of the operations, which was higher during the first 15 operations (6.8%) compared to the following 35 operations (2.3%). Length of stay reduced from median (range) 9 (2-39)-6 (2-127) days after 15 operations, but there was no reduction in maternal mortality. CONCLUSION: While gaining experience, the operation time of associate clinicians significantly reduced during the first 15 caesarean sections. Estimated bloodloss is not related to trainees experience.

[Two-year follow-up of infants born at 24 weeks gestation; first outcomes following implementation of the new 'Guideline for perinatal policy in cases of extreme prematurity']. / Follow-up na 2 jaar van kinderen geboren bij 24 weken.

OBJECTIVE: Since 2010 the guideline 'Guideline for perinatal policy in cases of extreme prematurity' has advised an active policy in infants born at 24 weeks gestation. We investigated how infants born at 24 and 25 weeks gestation in the first year following the implementation of the guideline had developed by the age of 2 years. DESIGN: Retrospective national cohort study. METHOD: The study population consisted of all surviving infants born in the Netherlands at 24 or 25 weeks gestation in the period from 1 October 2010 to 1 October 2011. At a corrected age of 2 years the children underwent a general physical and neurological examination, and their cognitive scores were determined on the 'Bayley scales of infant and toddler development' (Bayley III). Examinations took place in the 10 neonatal intensive care units (NICU's) in the Netherlands. RESULTS: Of 185 extremely premature infants, 166 were admitted to a NICU. A total of 95 survived to a corrected age of 2 years; 78 (82%) children were examined. Their average cognitive score on the Bayley III scale was 88 (SD: 16). Among the children born at 24 weeks gestation, 20% had mild disabilities and 20% had moderate to severe disabilities. Among the children born at 25 weeks gestation, 17% had mild disabilities and 12% had moderate to severe disabilities. CONCLUSION: Of the children born at 24 weeks gestation in the first year after the introduction of active policy in the Netherlands and surviving to 2 years of age (46%), more than half had developed without disabilities. This was comparable to children born at 25 weeks gestation. Of all children born at 24 weeks gestation, 25% survived to 2 years of age without disabilities.

Perceived quality of chronic illness care is associated with self-management: Results of a nationwide study in the Netherlands.

BACKGROUND: Healthcare providers are increasingly expected to help chronically ill patients understand their own central role in managing their illness. The aim of this study was to determine whether experiencing high-quality chronic illness care and having a nurse involved in their care relate to chronically ill people's self-management. METHODS: Survey data from 699 people diagnosed with chronic diseases who participated in a nationwide Dutch panel-study were analysed using linear regression analysis, to estimate the association between chronic illness care and various aspects of patients' self-management, while controlling for their socio-demographic and illness characteristics. RESULTS: Chronically ill patients reported that the care they received was of high quality to some extent. Patients who had contact with a practise nurse or specialised nurse perceived the quality of the care they received as better than patients who only had contact with a GP or medical specialist. Patients' perceptions of the quality of care were positively related to all aspects of their self-management, whereas contact with a practise nurse or specialised nurse in itself was not. CONCLUSION: Chronically ill patients who have the experience to receive high-quality chronic illness care that focusses on patient activation, decision support, goal setting, problem solving, and coordination of care are better self-managers. Having a nurse involved in their care seems to be positively valued by chronically ill patients, but does not automatically imply better self-management.

Effectiveness of tailored support for people with Type 2 diabetes after a first acute coronary event: a multicentre randomized controlled trial (the Diacourse-ACE study).

AIMS: To evaluate the effectiveness of a tailored, supportive intervention strategy in influencing diabetes-related distress, health status, well-being and clinical outcomes in people with Type 2 diabetes shortly after a first acute coronary event. METHODS: People with Type 2 diabetes and a recent first acute coronary event (n = 201) were randomized to the intervention group (three home visits by a diabetes nurse) or the attention control group (one telephone consultation). Outcomes were measured after discharge (baseline) and at 5 months (follow-up) using validated questionnaires for diabetes-related distress (Problem Areas in Diabetes), well-being (WHO Well-Being Index) and health status (Euroqol 5 Dimensions; Euroqol Visual Analogue Scale). ancova was used to analyse change-over-time differences between groups. RESULTS: Follow-up data were available for 81 participants in the intervention group (66.0 ± 9.3 years, 76% male) and 80 in the control group (65.6 ± 9.4 years, 75% male) participants. Mean diabetes-related distress was low after hospital discharge (intervention group: 8.2 ± 10.1; control group: 9.2 ± 12.4) and did not change after 5 months (intervention group: 9.2 ± 12.4; control group: 9.0 ± 11.2). Baseline well-being was less favourable but improved significantly in the intervention group (baseline: 58.5 ± 28.0; follow-up: 65.5 ± 23.7; P = 0.005), but not in the control group (baseline: 57.5 ± 25.2; follow-up: 59.6 ± 24.4; P = 0.481). Health status also improved in the intervention group (baseline: 69.9 ± 17.3; follow-up: 76.8 ± 15.6; P < 0.001) but not in the control group (baseline: 68.6 ± 15.9; follow-up: 69.9 ± 16.7; P = 0.470). A significant group effect was found for health status (F = 7.9; P = 0.006). CONCLUSIONS: Although the intervention had no effect on diabetes-related distress, this might be at least partially attributable to very low levels of diabetes-related distress at baseline. Interestingly, health status scores and well-being, which were less favourable at baseline, both improved after the tailored support intervention.

Long-term neurodevelopmental outcome after selective feticide in monochorionic pregnancies.

OBJECTIVE: To assess the incidence of and risk factors for adverse long-term neurodevelopmental outcome in complicated monochorionic pregnancies treated with selective feticide at our centre between 2000 and 2011. DESIGN: Observational cohort study. SETTING: National referral centre for fetal therapy (Leiden University Medical Centre, the Netherlands). POPULATION: Neurodevelopmental outcome was assessed in 74 long-term survivors. METHODS: Children, at least 2 years of age, underwent an assessment of neurologic, motor and cognitive development using standardised psychometric tests and the parents completed a behavioural questionnaire. MAIN OUTCOME MEASURES: A composite outcome termed neurodevelopmental impairment including cerebral palsy (GMFCS II-V), cognitive and/or motor test score of <70, bilateral blindness or bilateral deafness requiring amplification. RESULTS: A total of 131 monochorionic pregnancies were treated with selective feticide at the Leiden University Medical Centre. Overall survival rate was 88/131 (67%). Long-term outcome was assessed in 74/88 (84%). Neurodevelopmental impairment was detected in 5/74 [6.8%, 95% confidence interval (CI), 1.1-12.5] of survivors. Overall adverse outcome, including perinatal mortality or neurodevelopmental impairment was 48/131 (36.6%). In multivariate analysis, parental educational level was associated with cognitive test scores (regression coefficient B 3.9, 95% CI 1.8-6.0). Behavioural problems were reported in 10/69 (14.5%). CONCLUSIONS: Adverse long-term outcome in survivor twins of complicated monochorionic pregnancies treated with selective feticide appears to be more prevalent than in the general population. Cognitive test scores were associated with parental educational level. TWEETABLE ABSTRACT: Neurodevelopmental impairment after selective feticide was detected in 5/74 (6.8%, 95% CI 1.1-12.5) of survivors.

Diabetes-related distress over the course of illness: results from the Diacourse study.

AIMS: To investigate the relationship between diabetes duration and diabetes-related distress and to examine the impact of micro- and macrovascular complications and blood glucose-lowering treatment on this relationship. METHODS: We conducted a cross-sectional study in people with Type 2 diabetes who participated in the Dutch Diacourse study (n = 590) and completed the Problem Areas in Diabetes questionnaire. Data on diabetes duration, micro- and macrovascular complications and blood glucose-lowering treatment were collected. Multiple linear regression analysis was used to investigate the association between diabetes duration and diabetes-related distress, and to examine whether complications and treatment could explain this association. RESULTS: A significant linear and quadratic association between diabetes duration and diabetes-related distress was found (duration: ß = 0.27, P = 0.005; duration(2): ß = -0.21, P = 0.030). The association between duration and distress could be explained by microvascular complications and insulin treatment, which were both more often present in people with a longer diabetes duration, and were associated with higher levels of diabetes-related distress (ß = 0.20, P < 0.001 and ß = 0.16, P = 0.006 respectively). Duration, age, gender, complications and treatment together explained 13.1% of the variance in distress. CONCLUSIONS: Diabetes duration was associated with diabetes-related distress. This association can be explained largely by the presence of diabetes-related microvascular complications and insulin treatment. Healthcare providers should focus on distress in people with Type 2 diabetes in different stages over the course of illness, especially when complications are present or when people are on insulin treatment. As well as diabetes duration, complications and blood glucose-lowering treatment, diabetes-related distress is likely to be influenced by many other factors.

Neonatal thrombocytopenia after perinatal asphyxia treated with hypothermia: a retrospective case control study.

Our objective was to estimate the effect of therapeutic hypothermia on platelet count in neonates after perinatal asphyxia. We performed a retrospective case control study of all (near-) term neonates with perinatal asphyxia admitted between 2004 and 2012 to our neonatal intensive care unit. All neonates treated with therapeutic hypothermia were included in this study (hypothermia group) and compared with a historic control group of neonates with perinatal asphyxia treated before introduction of therapeutic hypothermia (2008). Primary outcome was thrombocytopenia during the first week after birth. Thrombocytopenia was found significantly more often in the hypothermia group than in the control group, 80% (43/54) versus 59% (27/46) (P = .02). The lowest mean platelet count in the hypothermia group and control group was 97 × 10(9)/L and 125 × 10(9)/L (P = .06), respectively, and was reached at a mean age of 4.1 days in the hypothermia group and 2.9 days in the control group (P < .001). The incidence of moderate/severe cerebral hemorrhage was 6% (3/47) in the hypothermia group versus 9% (3/35) in the control group (P = .64). In conclusion, neonates with perinatal asphyxia treated with therapeutic hypothermia are at increased risk of thrombocytopenia, without increased risk of cerebral hemorrhage.

Perinatal asphyxia in monochorionic versus dichorionic twins: incidence, risk factors and outcome.

OBJECTIVE: To estimate the incidence, risk factors, severity and outcome after perinatal asphyxia in monochorionic (MC) versus dichorionic (DC) twins. METHODS: We included all consecutive near-term MC and DC twins with perinatal asphyxia admitted to our neonatal ward between 2004 and 2013 and compared the perinatal characteristics and neonatal outcome between both groups. RESULTS: The incidence of perinatal asphyxia in MC and DC twin infants was 4.0 (11/272) and 4.0% (8/200; p = 1.00). In contrast to DC twins, asphyxia in MC twins was strongly associated with acute exsanguination and anemia at birth; 64% (7/11) in MC twins and 0% (0/8) in DC twins (p < 0.01). Median hemoglobin level at birth in the MC and DC groups was 11.5 and 18.6 g/dl, respectively (p < 0.01). CONCLUSIONS: Perinatal asphyxia in MC twins is often associated with severe anemia at birth due to acute hemorrhage through the placental vascular anastomoses.