Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants.

INTRODUCTION: Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited. METHODS: Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed. RESULTS: Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71). CONCLUSION: Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.

The impact of social distancing on community case count in the United States: Testing the efficacy of protection motivation theory during early stages of the COVID-19 pandemic.

Centuries of practice and an array of public health literature support social distancing (SD), or self-quarantine, as a valuable nonpharmaceutical intervention. To convince individuals to engage in behaviors that limit infection, public health professionals communicate risk and hazard based on application of protection motivation theory (PMT). The COVID-19 pandemic presents an opportunity to explore the efficacy of PMT in the context of a novel coronavirus with unique public health implications. We test an integrative conceptual model of social distancing compliance in U.S. counties and examine the mediating impact of SD on community spread of infection. We find that PMT does impact individual behavior, observing that the proportion of vulnerable populations affects social distancing compliance. However, actions to protect individual health are made within the context of economic concerns and priorities. While results indicate that PMT influences behavior, the expected relationship between that behavior and spread of disease in the community is not found. We do not repudiate SD or the value of PMT, but we suggest that these results may indicate that communication of risk in the context of COVID-19 may need community, as well as individual, framing.

Siglos de práctica y una variedad de literatura sobre salud pública apoyan el distanciamiento social, o la autocuarentena, como una valiosa intervención no farmacéutica. Para convencer a las personas de que adopten comportamientos que limiten la infección, los profesionales de la salud pública comunican el riesgo y el peligro basándose en la aplicación de la teoría de la motivación de protección. La pandemia de COVID­19 presenta una oportunidad para explorar la eficacia de la teoría de la motivación de protección en el contexto de un nuevo coronavirus con implicaciones únicas para la salud pública. Probamos un modelo conceptual integrador de cumplimiento del distanciamiento social en los condados de EE. UU. Y examinamos el impacto mediador del distanciamiento social en la propagación de la infección en la comunidad. Encontramos que la teoría de la motivación de protección sí impacta el comportamiento individual, observando que la proporción de poblaciones vulnerables afecta el cumplimiento del distanciamiento social. Sin embargo, las acciones para proteger la salud individual se realizan dentro del contexto de preocupaciones y prioridades económicas. Si bien los resultados indican que la teoría de la motivación de protección influye en el comportamiento, no se encuentra la relación esperada entre ese comportamiento y la propagación de la enfermedad en la comunidad. No repudiamos el distanciamiento social o el valor de la teoría de la motivación de protección, pero sugerimos que estos resultados pueden indicar que la comunicación del riesgo en el contexto de COVID­19 puede necesitar un marco comunitario, así como individual.

Widespread implementation of a low-cost telehealth service in the delivery of antenatal care during the COVID-19 pandemic: an interrupted time-series analysis.

BACKGROUND: Little evidence is available on the use of telehealth for antenatal care. In response to the COVID-19 pandemic, we developed and implemented a new antenatal care schedule integrating telehealth across all models of pregnancy care. To inform this clinical initiative, we aimed to assess the effectiveness and safety of telehealth in antenatal care. METHODS: We analysed routinely collected health data on all women giving birth at Monash Health, a large health service in Victoria (Australia), using an interrupted time-series design. We assessed the impact of telehealth integration into antenatal care from March 23, 2020, across low-risk and high-risk care models. Allowing a 1-month implementation period from March 23, 2020, we compared the first 3 months of telehealth integrated care delivered between April 20 and July 26, 2020, with conventional care delivered between Jan 1, 2018, and March 22, 2020. The primary outcomes were detection and outcomes of fetal growth restriction, pre-eclampsia, and gestational diabetes. Secondary outcomes were stillbirth, neonatal intensive care unit admission, and preterm birth (birth before 37 weeks' gestation). FINDINGS: Between Jan 1, 2018, and March 22, 2020, 20 031 women gave birth at Monash Health during the conventional care period and 2292 women gave birth during the telehealth integrated care period. Of 20 154 antenatal consultations provided in the integrated care period, 10 731 (53%) were delivered via telehealth. Overall, compared with the conventional care period, no significant differences were identified in the integrated care period with regard to the number of babies with fetal growth restriction (birthweight below the 3rd percentile; 2% in the integrated care period vs 2% in the conventional care period, p=0·72, for low-risk care models; 5% in the integrated care period vs 5% in the conventional care period, p=0·50 for high-risk care models), number of stillbirths (1% vs 1%, p=0·79; 2% vs 2%, p=0·70), or pregnancies complicated by pre-eclampsia (3% vs 3%, p=0·70; 9% vs 7%, p=0·15), or gestational diabetes (22% vs 22%, p=0·89; 30% vs 26%, p=0·06). Interrupted time-series analysis showed a significant reduction in preterm birth among women in high-risk models (-0·68% change in incidence per week [95% CI -1·37 to -0·002]; p=0·049), but no significant differences were identified in other outcome measures for low-risk or high-risk care models after telehealth integration compared with conventional care. INTERPRETATION: Telehealth integrated antenatal care enabled the reduction of in-person consultations by 50% without compromising pregnancy outcomes. This care model can help to minimise in-person interactions during the COVID-19 pandemic, but should also be considered in post-pandemic health-care models. FUNDING: None.

Staff awareness and bundling reduce skin breaks and blood tests in neonatal intensive care.

AIM: Skin breaks (SBs) for procedures and blood sampling are common in neonatal intensive care units (NICU), contributing to pain, infection risk and anaemia. We aimed to document their prevalence, identify areas for improvement and, through staff awareness, reduce their frequency. METHODS: Quality improvement project via prospective audit at a tertiary-level NICU in Australia was conducted. All infants admitted to the NICU for >24 h during two audit periods were included in the study. A specifically designed bedside audit tool was used to prospectively document all SB and blood tests performed on infants during a 4-week audit period (audit 1). Results were reviewed to identify areas for improvement, and disseminated to staff at unit meetings, shift handover and email. Following education and awareness, the audit was repeated (audit 2), and data were compared. Frequency of SB and blood tests performed was measured. Data were tested for normality and analysed using parametric or non-parametric tests where appropriate. RESULTS: There were 52 NICU admissions during each audit period (104 total), with 34 (65%) and 31 (60%) having audit sheets completed, respectively. Median (interquartile range) gestational age and mean (standard deviation) birthweight were 29 (26.3-35) weeks and 1836 (1185) g for audit 1, 30 (28.5-31.5) weeks and 1523 (913) g for audit 2. The reduction in total blood tests (mean) was 36.3%, skin breaks per admitted baby day reduced by 60% and total blood volume sampled (mean) by 37.7%. CONCLUSIONS: A quality improvement project by prospective audit and staff education was associated with reductions in frequency of skin breaks and blood tests in the NICU.

In utero fetal left ventricular rupture and pseudoaneurysm formation: a case report.

BACKGROUND: Cardiac ventricular aneurysms affect 1 in 200,000 live births. To the best of our knowledge, no reported cases of a left ventricular pseudoaneurym and in utero rupture exist to guide optimal management. CASE PRESENTATION: We present a case of fetal left ventricular rupture with a large pericardial effusion, cardiac tamponade and subsequent pseudoaneurysm formation with concerns for a poor prognosis. Interventional drainage of the pericardial effusion led to resolution of tamponade and significant improvement in fetal condition. A multidisciplinary team was utilised to plan birth to minimise risk of pseudoaneurysmal rupture and a catastrophic bleed at birth. CONCLUSION: For similar cases we recommend consideration of birth by caesarean section, delayed cord clamping and a prostaglandin E1 infusion, to reduce the systemic pressures on the left ventricle during transition from fetal to neonatal circulations, until definitive surgical repair. In this case, this resulted in a successful outcome.

Changing consumption of resources for respiratory support and short-term outcomes in four consecutive geographical cohorts of infants born extremely preterm over 25 years since the early 1990s.

OBJECTIVES: It is unclear how newer methods of respiratory support for infants born extremely preterm (EP; 22-27 weeks gestation) have affected in-hospital sequelae. We aimed to determine changes in respiratory support, survival and morbidity in EP infants since the early 1990s. DESIGN: Prospective longitudinal cohort study. SETTING: The State of Victoria, Australia. PARTICIPANTS: All EP births offered intensive care in four discrete eras (1991-1992 (24 months): n=332, 1997 (12 months): n=190, 2005 (12 months): n=229, and April 2016-March 2017 (12 months): n=250). OUTCOME MEASURES: Consumption of respiratory support, survival and morbidity to discharge home. Cost-effectiveness ratios describing the average additional days of respiratory support associated per additional survivor were calculated. RESULTS: Median duration of any respiratory support increased from 22 days (1991-1992) to 66 days (2016-2017). The increase occurred in non-invasive respiratory support (2 days (1991-1992) to 51 days (2016-2017)), with high-flow nasal cannulae, unavailable in earlier cohorts, comprising almost one-half of the duration in 2016-2017. Survival to discharge home increased (68% (1991-1992) to 87% (2016-2017)). Cystic periventricular leukomalacia decreased (6.3% (1991-1992) to 1.2% (2016-2017)), whereas retinopathy of prematurity requiring treatment increased (4.0% (1991-1992) to 10.0% (2016-2017)). The average additional costs associated with one additional infant surviving in 2016-2017 were 200 (95% CI 150 to 297) days, 326 (183 to 1127) days and 130 (70 to 267) days compared with 1991-1992, 1997 and 2005, respectively. CONCLUSIONS: Consumption of resources for respiratory support has escalated with improved survival over time. Cystic periventricular leukomalacia reduced in incidence but retinopathy of prematurity requiring treatment increased. How these changes translate into long-term respiratory or neurological function remains to be determined.

Reference intervals for neonatal thyroid function tests in the first 7 days of life.

BACKGROUND: Prompt intervention can prevent permanent adverse neurological effects caused by neonatal hypothyroidism. Thyroid function changes rapidly in the first few days of life but well-defined age-specific reference intervals (RIs) for thyroid-stimulating hormone (TSH), free thyroxine (FT4) and free tri-iodothyronine (FT3) are not available to aid interpretation. We developed hour-based RIs using data mining. METHODS: All TSH, FT4 and FT3 results with date and time of collection from neonates aged <7 days during 2005-2015 were extracted from the Monash Pathology database. Neonates with more than one episode of testing or with known primary hypothyroidism, identified by treating physicians or from medical records, were excluded from the analysis. The date and time of birth were obtained from the medical records. RESULTS: Of the 728 neonates qualifying for the study, 569 had time of birth available. All 569 had TSH, 415 had FT4 and 146 had FT3 results. For age ≤24 h, 25-48 h, 49-72 h, 73-96 h, 97-120 h, 121-144 h and 145-168 h of life, the TSH RIs (2.5th-97.5th) (mIU/L) were 4.1-40.2, 3.2-29.6, 2.6-17.3, 2.2-14.7, 1.8-14.2, 1.4-12.7 and 1.0-8.3, respectively; the FT4 RIs (mean ± 2 standard deviation [SD]) (pmol/L) were 15.3-43.6, 14.7-53.2, 16.5-45.5, 17.8-39.4, 15.3-32.1, 14.5-32.6 and 13.9-30.9, respectively; the FT3 RIs (mean±2 SD) (pmol/L) were 5.0-9.4, 4.1-9.1, 2.8-7.8, 2.9-7.8, 3.5-7.2, 3.4-8.0 and 3.8-7.9, respectively. CONCLUSIONS: TSH and FT4 were substantially high in the first 24 h after birth followed by a rapid decline over the subsequent 168 h. Use of hour-based RIs in newborns allows for more accurate identification of neonates who are at risk of hypothyroidism.

Outcomes of standardised approach to metabolic bone disease of prematurity.

AIM: To assess the current protocol of metabolic bone disease (MBD) at three Monash Health neonatal units (Melbourne, Australia). METHODS: Retrospective audit of 171 infants born at <32 weeks' gestation over 18 months. Mean gestational age was 28.6 ± 2.1 weeks, and birthweight was 1190 ± 374 g. Risk factors of MBD include intra-uterine growth retardation (n = 33, 19.3%), maternal pre-eclampsia (n = 17, 9.9%), necrotising enterocolitis (n = 9, 5.4%) and medications like methylxanthines (94.2%; mean 54.8 days), diuretics (38.6%; mean 49.2 days) and glucocorticoids (5.3%; mean 35 days). RESULTS: In total, 84.8% infants had an initial MBD screen (mean age 36.3 days), with 45% having repeated monitoring (mean age 71.9 days), and 14.2% had initial alkaline phosphatase levels >500 U/L, decreasing to 10.1% on follow-up. All infants received additional vitamin D supplementation of 400 IU/day, phosphate of 25.1% (n = 43) and calcium of 19.9% (n = 34). Fractures were identified from clinical documentation in 2.9% (n = 5) of infants. Stratifying into phosphate-treated and untreated groups revealed significant differences (P < 0.001) for gestational age and birthweight: 26.7 ± 1.7 weeks/918 ± 272 g for treated versus 29.2 ± 1.9 weeks/1283 ± 359 g for untreated. In the phosphate-treated group, improvement was seen in mean alkaline phosphatase (pre-treatment 467 ± 204 U/L and post-treatment 342 ± 221 U/L, P < 0.01) and mean phosphate levels (1.8 ± 0.4 vs. 2.2 ± 1.0 mmol/L, P < 0.01). Linear growth difference between phosphate-treated (n = 10) and untreated groups (n = 24) was insignificant at >6 months of age (P = 0.13), although this may reflect limited data. CONCLUSION: Adequate first-line supplementation with vitamin D and phosphate appeared to improve biochemical markers of MBD, but given the observational nature of this study, further longitudinal/prospective studies are required to confirm these findings.

The Use of Peritoneal Dialysis in Phenobarbitone Toxicity in a Critically Unwell Neonate.

BACKGROUND: Phenobarbitone (PB) is the first-line anti-convulsant for neonatal seizures. The use of peritoneal dialysis (PD) to enhance drug elimination in cases of neonatal PB overdose has not been reported. OBJECTIVE: To report a case of neonatal severe PB toxicity and review the elimination of PB by PD. METHODS: Assessment of PD drug clearance. RESULTS: A neonate with prolonged seizures was administered PB. Encephalopathy and myocardial failure developed, which were initially suspected to be secondary to hypoxia. At 42 h of age, the serum PB concentration was in the toxic range at 131 mg/L. Despite supportive care, the infant's condition deteriorated with escalating inotropes and the need for CPR. Enhanced PB elimination via multiple-dose activated charcoal and exchange transfusion were considered too risky. Hourly PD cycles via Tenckhoff catheter were commenced, based on reports suggesting that PD enhances PB clearance. The clinical state of the infant then improved. PD administration was continued for 60 h, recovering 20% of the estimated total PB body load. The infant survived and there were no PD complications. CONCLUSIONS: PD increased PB clearance in this neonate, correlating with clinical recovery. Where other techniques are not possible, PD may have a role to play in enhancing PB elimination.

CeasIng Cpap At standarD criteriA (CICADA): impact on weight gain, time to full feeds and caffeine use.

INTRODUCTION: In our previous randomised controlled trial (RCT), we have shown in preterm babies (PBs) <30 weeks gestation that CeasIng Cpap At standarD criteriA (CICADA (method 1)) compared with cycling off continuous positive airway pressure (CPAP) gradually (method 2) or cycling off CPAP gradually with low flow air/oxygen during periods off CPAP (method 3) reduces CPAP cessation time in PBs <30 weeks gestation. METHOD: This retrospective study reviewed weight gain, time to reach full feeds and time to cease caffeine in PBs previously enrolled in the RCT. RESULTS: Data were collected from 162 of the 177 PBs, and there was no significant difference in the projected weight gain between the three methods. Based on intention to treat, the time taken to reach full feeds for all three methods showed no significant difference. However, post hoc analysis showed the CICADA method compared with cycling off gradually just failed significance (30.3±1.6 vs 31.1±2.4 (weeks corrected gestational age (Wks CGA±SD)), p=0.077). Analysis of time to cease caffeine showed there was a significant difference between the methods with PBs randomised to the CICADA method compared with the cycling off method ceasing caffeine almost a week earlier (33.6±2.4 vs 34.5±2.8 (Wks CGA±SD), p=0.02). CONCLUSIONS: This retrospective study provides evidence to substantiate the optimum method of ceasing CPAP; the CICADA method, does not adversely affect weight gain, time to reach full feeds and may reduce time to cease caffeine in PBs <30 weeks gestation.

A randomised controlled trial of blended learning to improve the newborn examination skills of medical students.

OBJECTIVE: To evaluate the hypotheses that a blended learning approach would improve the newborn examination skills of medical students and yield a higher level of satisfaction with learning newborn examination. METHOD: Undergraduate medical students at a tertiary teaching hospital were individually randomised to receive either a standard neonatology teaching programme (control group), or additional online access to the PENSKE Baby Check Learning Module (blended learning group). The primary outcome was performance of newborn examination on standardised assessment by blinded investigators. The secondary outcomes were performance of all 'essential' items of the examination, and participant satisfaction. RESULTS: The recruitment rate was 88% (71/81). The blended learning group achieved a significantly higher mean score than the control group (p=0.02) for newborn examination. There was no difference for performance of essential items, or satisfaction with learning newborn examination. The blended learning group rated the module highly for effective use of learning time and ability to meet specific learning needs. CONCLUSIONS: A blended learning approach resulted in a higher level of performance of newborn examination on standardised assessment. This is consistent with published literature on blended learning and has implications for all neonatal clinicians including junior doctors, midwifes and nurse practitioners.

Prophylactic antibiotics to reduce morbidity and mortality in newborn infants with intercostal catheters.

BACKGROUND: Intercostal catheters are commonly used for the drainage of intrathoracic collections in newborn infants, including pneumothorax and pleural effusions. Placement of an intercostal drain is a potential risk factor for nosocomial infection due to breach of the cutaneous barrier. Therefore, neonates who require intercostal drainage, especially those in high risk groups for nosocomial infection, may benefit from antibiotic prophylaxis. However, injudicious antibiotic use carries the risk of promoting the emergence of resistant strains of micro-organisms or of altering the pattern of pathogens causing infection. OBJECTIVES: To determine the effect of prophylactic antibiotics compared to selective use of antibiotics on mortality and morbidity (especially septicaemia) in neonates undergoing placement of an intercostal catheter. SEARCH METHODS: The standard search strategy of the Cochrane Neonatal Review Group was used to search the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 5), MEDLINE (1948 to June 2011) and CINAHL (1982 to June 2011). SELECTION CRITERIA: Randomised controlled trials or some types of non-randomised (that is, quasi-randomised) controlled trials of adequate quality in which either individual newborn infants or clusters of infants were randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: We used the standard methods of the Cochrane Neonatal Review Group. MAIN RESULTS: We did not find any randomised controlled trials that met the eligibility criteria. AUTHORS' CONCLUSIONS: There are no data from randomised trials to either support or refute the use of antibiotic prophylaxis for intercostal catheter insertion in neonates. Any randomised controlled trials of antibiotic prophylaxis would need to account for the fact that neonates who require insertion of an intercostal catheter may already be receiving antibiotics for other indications.

The importance of a servant leader orientation.

BACKGROUND: Ensuring a quality nursing workforce for the future in a time of increasing labor shortage and declining nurse satisfaction is a key challenge to the health care industry. Understanding what impacts job satisfaction is vital to solving the problem of nurse attrition. PURPOSES: We suggest that the approach to supporting staff in the care giving role requires additional expectations of managers who supervise inpatient nursing staff. This study empirically tested the impact of nurse managers' servant leadership orientation on nurse job satisfaction. METHODOLOGY/APPROACH: Nurses providing direct bedside patient care within inpatient departments of a five-hospital system were asked to respond to four questionnaires. Seventeen departments participated. There were 346 available nurses across the departments. The average response rate was 73% across all of the units surveyed. Hypotheses were tested using multivariate regression analysis of the nurse-nurse manager dyad. FINDINGS: Statistical findings of this study provided evidence that behaviors and attitudes of the nurse manager do impact employee job satisfaction. Departments where staff perceived that managers had higher servant leadership orientation demonstrated significant positive impact on individual employee job satisfaction. PRACTICE IMPLICATIONS: Nursing is a unique occupation in that it requires both competence in professional service and compassion in patient caregiving. Hospitals are not factories dealing with inanimate objects or data. The results of this research suggested that the management approach in a health care environment might be enhanced by a more servant-oriented management approach. Specific policy changes that may be implied on the basis of findings of this research include key areas of management selection, management development, and management reward/evaluation.