Assessment of the Complications of Peripherally Inserted Central Catheter in Neonates Admitted to the Intensive Care Unit: A Center's Experience in Iran.

Background: Peripherally Inserted Central Catheter (PICC), which is inserted through peripheral veins into the superior or inferior vena cava, is used to inject medications or parenteral nutrition in neonates with long-term hospitalization in the intensive care unit. In this study, we assessed the complications of PICC in neonates admitted to the intensive care unit in hospital. Materials and Methods: In the present retrospective cohort, neonates admitted to the Neonatal Intensive Care Unit (NICU) of Valiasr Hospital during 2015-2018 had been divided into two groups with PICC and without it. Data included the occurrence of septicemia, tachycardia, perforation of large veins, pulmonary hypertension, cardiac tamponade, pericardial effusion, catheter site necrosis, hemorrhage, anemia, pleural effusion, ascites, phlebitis of catheter track and neonatal death, which were collected, using the comprehensive neonatal registry of Valiasr Hospital. Data analysis was performed with regression, mantel-haenszel and independent t-test. Results: Data from 174 neonates with PICC were compared to 207 infants with classic IV-Line. In the exposure group, the gestational age and birth weight were lower. Based on the results of the double logistic regression test, septicemia and hemorrhage in the injection site, independent of other variables, were related to the use of PICC and the risk of septicemia or hemorrhage in the injection site was significantly reduced if PCIC was used (p < 0.01). Conclusions: Using the PICC as a therapeutic procedure in hospitalized neonates in the NICU is a safe method. By improving its replacement skills among physicians and nurses, its side effects are minor and negligible.

Tehran environmental and neurodevelopmental disorders (TEND) cohort study: Phase I, feasibility assessment.

PURPOSE: To advance knowledge about childhood neurodevelopmental disorders and study their environmental determinants, we conducted a study in Tehran, Iran to assess the feasibility of prospective birth cohort study. METHODS: We evaluated participation of pregnant women, feasibility of sampling biological material, and health care services availability in Tehran in four steps: (1) first trimester of pregnancy; (2) third trimester of pregnancy; (3) at delivery; and (4) two to three months after delivery. We collected related data through questionnaires, also various biological samples were obtained from mothers (blood, urine, milk and nails-hands and feet) and newborns (umbilical cord blood, meconium, and urine samples) from February 2016 to October 2017. RESULTS: overall 838 eligible pregnant women were approached. The participation rate was 206(25%) in our study and about 185(90%) of subjects were recruited in hospitals. Out of 206 participants in the first trimester, blood, urine, hand nail, and foot nail samples were collected from 206(100%),193(93%), 205(99%), and 205(99%), respectively. These values dropped to 65(54%), 83(69%), 84(70%), and 84(70%) for the remaining participants 120(58%) in the third trimester, respectively. Also, we gathered milk samples from 125(60%) of mothers at two to three months after delivery. CONCLUSION: Our findings suggest that hospitals were better places for recruitment of subjects in a birth cohort in Tehran. We further concluded that birth cohort study recruitment can be improved by choosing appropriate gestational ages. Obtaining the newborn's urine, meconium, and umbilical cord blood were challenging procedures and require good collaboration between hospital staff and researchers.

Review of the Iranian Newborns' Health, Survival, and Care and Future Challenges.

INTRODUCTION: Providing, maintaining, and improving the health of newborns is one of the most important goals of the health care system in the Islamic Republic of Iran. On the eve of the 40th anniversary of the Islamic Revolution of Iran, we will review factors affecting the health of Iranian neonates over the past 40 years. METHODS: We investigated the evolution of neonatal health and contributing factors in all reports, documents, and articles published by the Iranian Ministry of Health and Medical Education and the former Iranian Ministry of Health as well as WHO, and UNICEF databases from 1970 to 2018. The main topics of the present study include recent developments in reduction of maternal and neonatal mortality, major measures taken to decrease risk of neonatal death, and future challenges. RESULTS: We have reviewed more than 3500 pages of documents and articles published by authoritative sources before and after the Islamic Revolution. A neonatal mortality rate (NMR) of 9.6 per 1000 in 2017 was recordred in Iran, demonstrating a reduction of over three-quarters compared with the pre-Revolution period. Improved prenatal care and nutrition, tetanus vaccination of pregnant mothers, performance of 96.4% of deliveries by trained individuals, circulation of clinical protocols for the integration of midwifery and maternity services, provision of neonatal resuscitation equipment in delivery rooms, promotion of breastfeeding from the first hour after birth onward, establishing and equipping NICUs, increased training of specialists and sub-specialists, prevention and treatment of infections, increasing awareness in families and family-centered neonatal care focused on neonatal brain development, the Newborn Indivisualized Developmental Care and Assessment Program (NIDCAP) and Kangaroo-Mother Care (KMC) are examples of progress made in neonate healthcare after the Islamic Revolution. CONCLUSION: Despite 8 years of war and a variety of sanctions being imposed against I.R. of Iran, very substantial improvements have been achieved in neonatal health and relevant underlying factors. However, we are still faced with challenges that require the engagement of experts and researchers in neonatal medicine.

A study of the validity and reliability of the questionnaire entitled "physicians' approach to and disclosure of medical errors and the related ethical issues".

Medical errors are among the major challenges that threaten patients' health worldwide. The aim of this study was to design a valid and reliable questionnaire to investigate the status of medical error disclosure by physicians. A preliminary questionnaire was developed based on the extracted results from 37 interviews with specialists. To test the validity of the questionnaire, 20 medical practitioners and medical ethics authorities were asked to evaluate the relevance and clarity of each item. To measure the instrument's reliability (the intra-class correlation coefficient and Cronbach's alpha), a test-retest study was conducted on 20 randomly selected physicians twice with a 2-week interval. Statistical analyses were performed using SPSS software version 20. The overall relevance and clarity of the instrument, with an average approach, were measured at 97.22 and 94.03 percent respectively. The Cronbach's alpha, which presents the internal consistency was satisfactory (0.70 - 0.79) for various domains of the questionnaire. The range of intra-class correlation coefficients for the items in all domains of the questionnaire was 0.76 to 1.00. Regarding the validity and reliability of the questionnaire, it can be an appropriate instrument in the assessment and monitoring of the status of medical error disclosure by physicians.

An agent based architecture for high-risk neonate management at neonatal intensive care unit.

BACKGROUND: In recent years, the use of new tools and technologies has decreased the neonatal mortality rate. Despite the positive effect of using these technologies, the decisions are complex and uncertain in critical conditions when the neonate is preterm or has a low birth weight or malformations. There is a need to automate the high-risk neonate management process by creating real-time and more precise decision support tools. OBJECTIVE: To create a collaborative and real-time environment to manage neonates with critical conditions at the NICU (Neonatal Intensive Care Unit) and to overcome high-risk neonate management weaknesses by applying a multi agent based analysis and design methodology as a new solution for NICU management. METHODS: This study was a basic research for medical informatics method development that was carried out in 2017. The requirement analysis was done by reviewing articles on NICU Decision Support Systems. PubMed, Science Direct, and IEEE databases were searched. Only English articles published after 1990 were included; also, a needs assessment was done by reviewing the extracted features and current processes at the NICU environment where the research was conducted. We analyzed the requirements and identified the main system roles (agents) and interactions by a comparative study of existing NICU decision support systems. The Universal Multi Agent Platform (UMAP) was applied to implement a prototype of our multi agent based high-risk neonate management architecture. RESULTS: Local environment agents interacted inside a container and each container interacted with external resources, including other NICU systems and consultation centers. In the NICU container, the main identified agents were reception, monitoring, NICU registry, and outcome prediction, which interacted with human agents including nurses and physicians. CONCLUSION: Managing patients at the NICU units requires online data collection, real-time collaboration, and management of many components. Multi agent systems are applied as a well-known solution for management, coordination, modeling, and control of NICU processes. We are currently working on an outcome prediction module using artificial intelligence techniques for neonatal mortality risk prediction. The full implementation of the proposed architecture and evaluation is considered the future work.

Effects of cannabinoid receptor type 2 in respiratory syncytial virus infection in human subjects and mice.

An accumulating body of evidence suggests that the endocannabinoid system plays a significant role in pathophysiological processes and impacts disease severity. Here we investigate the possible role of a cannabinoid receptor type 2 (CB2) functional variant in determining disease severity and the potential pharmacological therapeutic effects of CB2 activation in viral respiratory infection. The common missense variant (CAA/CGG; Q63R) of the gene-encoding CB2 receptor (CNR2) was evaluated in 90 inpatient and 90 outpatient children with acute respiratory tract infection (ARTI). The frequency distribution of respiratory syncytial virus (RSV)-the main cause of severe cases of bronchiolitis and pneumonia in children-was studied in all collected samples. The mechanism through which CB2 affects clinical outcomes in case of RSV infection was studied in Balb/c mice model using AM630 as a CB2 antagonist. The potential therapeutic effect of CB2 activation during RSV infection was studied using a selective agonist, JWH133. The CB2 Q63R variation was associated with increased risk of hospitalization in children with ARTI. Children carrying the QQ genotype were more prone to developing severe ARTI (OR = 3.275, 95% CI: 1.221-8.705; p = 0.019). Of all the children enrolled in the study, 83 patients (46.1%) were found positive for RSV infection. The associated risk of developing severe ARTI following RSV infection increased more than two-fold in children carrying the Q allele (OR = 2.148, 95% CI: 1.092-4.224; p = 0.026). In mice, the blockade of CB2 by AM630 during RSV infection enhanced the influx of BAL cells and production of cytokines/chemokines while exaggerating lung pathology. CB2 activation by JWH133 reduces the influx of BAL cells and production of cytokines/chemokines while alleviating lung pathology. Collectively, CB2 is associated with RSV severity during infancy and may serve as a therapeutic target in RSV infection through the alleviation of virus-associated immunopathology.

Comparison of INSURE method with conventional mechanical ventilation after surfactant administration in preterm infants with respiratory distress syndrome: therapeutic challenge.

Administration of endotracheal surfactant is potentially the main treatment for neonates suffering from RDS (Respiratory Distress Syndrome), which is followed by mechanical ventilation. Late and severe complications may develop as a consequence of using mechanical ventilation. In this study, conventional methods for treatment of RDS are compared with surfactant administration, use of mechanical ventilation for a brief period and NCPAP (Nasal Continuous Positive Airway Pressure), (INSURE method ((Intubation, Surfactant administration and extubation)). A randomized clinical trial study was performed, including all newborn infants with diagnosed RDS and a gestational age of 35 weeks or less, who were admitted in NICU of Valiasr hospital. The patients were then divided randomly into two CMV (Conventional Mechanical Ventilation) and INSURE groups. Surfactant administration and consequent long-term mechanical ventilation were done in the first group (CMV group). In the second group (INSURE group), surfactant was administered followed by a short-term period of mechanical ventilation. The infants were then extubated, and NCPAP was embedded. The comparison included crucial duration of mechanical ventilation and oxygen therapy, IVH (Intraventricular Hemorrhage), PDA (Patent Ductus Arteriosus), air-leak syndromes, BPD (Broncho-Pulmonary Dysplasia) and mortality rate. The need for mechanical ventilation in 5th day of admission was 43% decreased (P=0.005) in INSURE group in comparison to CMV group. A decline (P=0.01) in the incidence of IVH and PDA was also achieved. Pneumothorax, chronic pulmonary disease and mortality rates, were not significantly different among two groups. (P=0.25, P=0.14, P=0.25, respectively). This study indicated that INSURE method in the treatment of RDS decreases the need for mechanical ventilation and oxygen-therapy in preterm neonates. Moreover, relevant complications as IVH and PDA were observed to be reduced. Thus, it seems rationale to perform this method as the initial treatment for neonates with mild to moderate RDS.

Comparison of High Frequency Positive Pressure Mechanical Ventilation (HFPPV) With Conventional Method in the Treatment of Neonatal Respiratory Failure.

BACKGROUND: Respiratory failure is a major problem in neonatal medicine in all over the world and has different causes. Using mechanical ventilation is one of its major treatments. OBJECTIVES: Different strategies have been expressed in this context, including high frequency mechanical ventilation. PATIENTS AND METHODS: This study is a prospective randomized clinical trial conducted on all newborns with respiratory failure hospitalized in the NICU of Tehran vali-asr Hospital during 2009.These patients were divided in to two groups through block Randomization method; conventional mechanical ventilation group and high frequency ventilation group. RESULTS: Intraventricular hemorrhage (IVH) and air leak (e.g. pneumothorax) were less in HFPPV group than conventional group (P = 0.012 and P = 0.038). The mean time needed for mechanical ventilation was lower in HFPPV group, but this difference was not statistically significant (P = 0.922). Needing to O2 in 28 days of age was almost equal in both groups (P = 0. 99). Mortality, and refractory hypoxia and PVL were lower in HFPPV group, but the difference was not statistically significant (P = 0.301, P = 0. 508, P = 0. 113). CONCLUSIONS: Treatment of neonatal respiratory failure with high rate mechanical ventilation may reduce some complications.