The Schweitzer effect: The fundamental relationship between experience and medical students' opinions on professional behaviours.

PURPOSE: We examined whether medical students' opinions on the acceptability of a behaviour were influenced by previously encountering a similar professionally challenging situation, assessed the magnitude of effect of 'experience' compared to other demographic factors which influence medical students' opinions, and evaluated whether opinions regarding some situations/behaviours were more susceptible to 'experience' bias? METHODS: Confidential, on-line survey for medical students distributed to Australian and New Zealand (AUS/NZ) medical schools. Students submitted de-identified demographic information, provided opinions on the acceptability of a wide range of student behaviours in professionally challenging situations, and whether they had encountered similar situations. RESULTS: 3171 students participated from all 21 Aus/NZ medical schools (16% of registered students). Medical students reported encountering many of the professionally challenging situations, with varying opinions on what was acceptable behaviour. The most significant factor influencing acceptability towards a behaviour was whether the student reported encountering a similar situation. The professional dilemmas most significantly influenced by previous experience typically related to behaviours that students could witness in clinical environments, and often involved breaches of trust. CONCLUSIONS: Our results demonstrate the relationship between experience and medical students' opinions on professional behaviour- the 'Schweitzer effect'. When students encounter poor examples of professional behaviour, especially concerning trust breaches, it significantly influences their perception of the behaviour. These results highlight the importance of placing students in healthcare settings with positive professional role modelling/work cultures.

Medical students report encountering a wide range of professionally challenging situations, and have varying opinions on acceptable professional behavioursAlthough medical students' opinions on professional behaviours are influenced by their demography, the most significant factor influencing the acceptability towards a behaviour was whether the student reported encountering a similar professional dilemmaStudents appear to be susceptible to normalising counter productive work behaviours, particularly those related to breaches of trustBy placing students in toxic work culture environments with poor role models, we may inadvertently enable healthcare systems to perpetuate poor professional behaviour.

Outcomes to 5 years of outborn versus inborn infants <32 weeks in Western Australia: a cohort study of infants born between 2005 and 2018.

OBJECTIVE: We compared mortality and morbidity of inborn versus outborn very preterm infants <32 weeks' gestation in Western Australia (WA) between 2005 and 2018. DESIGN: Retrospective cohort study. PATIENTS: Infants <32 weeks' gestation who were born in WA. MAIN OUTCOME MEASURES: Mortality was assessed as death before discharge home from the tertiary neonatal intensive care unit. Short-term morbidities included combined brain injury (intracranial haemorrhage grade ≥3 and cystic periventricular leukomalacia) and other major neonatal outcomes. Developmental assessments at age 2, 3 and 5 years were evaluated. We performed multivariable logistic regression analysis of outborn status on outcomes, controlling for gestational age, birth weight z-score, sex and multiple birth. RESULTS: A total of 4974 infants were born in WA between 22 and 32 weeks' gestation between 2005 and 2018 of which 4237 (89.6%) were inborn and 443 (10.4%) were outborn. Overall mortality to discharge was higher in outborn infants (20.5% (91/443) vs 7.4% (314/4237); adjusted OR (aOR) 2.44, 95% CI 1.60 to 3.70, p<0.001). Outborn infants had higher rates of combined brain injury than those inborn (10.7% (41/384) vs 6.0% (246/4115); aOR 1.98, 95% CI 1.37 to 2.86), p<0.001). No difference in up to 5-year developmental measures was detected. Follow-up data were available for 65% of outborn and 79% of inborn infants. CONCLUSIONS: Outborn preterm infants <32 weeks in WA had increased odds of mortality and combined brain injury than those inborn. Developmental outcomes up to 5 years were similar between groups. Loss to follow-up may have impacted the long-term comparison.

Consistency in the transabdominal ultrasound measurement of cervical length in mid-pregnancy.

Purpose: The Western Australian Preterm Birth Prevention Initiative recommends a transabdominal cervical length (TACL) measurement at the mid-pregnancy ultrasound to screen low-risk women for preterm birth risk. In view of this recommendation, we assessed the inter-observer consistency of TACL screening in mid-pregnancy. Methods: Routinely collected mid-pregnancy TACL ultrasound images were graded from 0 to 4 according to the anatomical landmarks identified by a single expert. A random selection of 10 images of each grade were disseminated in an electronic survey to determine inter- and intra-observer variations in the classification of the cervical image. Results: A total of 244 participants graded 50 TACL images. Six participants repeated the grading. Overall agreement to the exact initial grade for all images was 49.6%, highest for images at both ends of the spectrum (83% Grade 0 and 70.4% for Grade 4). Overall agreement to the initial diagnostic Grades 3 and 4 was 75.3% (95% CI 74.5-76.0%) and was higher when the maternal bladder was empty. There was moderate inter-rater agreement (κ = 0.42) for Grades 3 and 4 (diagnostic) or Grades 1 and 2 (non-diagnostic). The intra-rater agreement was fair to good (κ = 0.59, 95% CI 0.49-0.70) for those who repeated the assessment (including the expert grader). Conclusions: Sonographic CL screening is considered an important tool for the identification of women at high risk of preterm birth. Image classification of TACL performed poorly compared with previous studies assessing transvaginal cervical length. Improved reliability and measurement consistency may be achieved through high levels of quality assurance, ongoing training and image audit.

The clinical utility of ongoing sonographic cervix length surveillance in pregnancies prescribed vaginal progesterone therapy.

BACKGROUND: Vaginal progesterone therapy significantly reduces preterm birth (PTB) rates in those high-risk pregnancies with a sonographic short cervix (≤25 mm) and/or a history of spontaneous PTB. Cervical length (CL) is routinely measured at the midtrimester morphology scan; however, CL surveillance thereafter is not currently recommended. Progesterone's precise mechanism of action remains unknown, though if it indeed influences CL, shortening after treatment initiation could indicate therapeutic failure and risk of PTB. AIMS: The aim was to explore the utility of serial transvaginal ultrasound (TVU) measurement of CL at 16, 19 and 22 weeks for predicting PTB in high-risk pregnancies prescribed progesterone therapy. METHODS: A retrospective cohort study was conducted involving women who attended the King Edward Memorial Hospital PTB Prevention Clinic from 2015 to 2019 and were prescribed progesterone therapy. CL was measured at 16, 19 and 22 weeks by TVU. CL change across three time points was assessed using linear mixed models; then relationships between CL change between 16-19 and 19-22 weeks and PTB were analysed using logistic regression models. RESULTS: Term birth was most likely when CL did not decrease across both time periods. The addition of 16-19 week decrease in CL to a model, including CL at 19 weeks alone, for predicting PTB increased sensitivity from 43.2 to 56.3%, specificity from 73.2 to 77.4%, and overall accuracy from 61.7 to 70.2%. CONCLUSION: For high-risk women prescribed vaginal progesterone therapy, serial measurement of the cervix at 16 and 19 weeks improves clinical ability to predict PTB from current recommendations of 19-week measurement alone.

Why Is Patient Safety a Challenge? Insights From the Professionalism Opinions of Medical Students' Research.

OBJECTIVES: Despite increased emphasis on education and training for patient safety in medical schools, there is little known about factors influencing decision making regarding patient safety behaviors. This study examined the nature and magnitude of factors that may influence opinions around patient safety-related behaviors as a means of providing insights into how Australian doctors and medical students view these issues relative to members of the public. METHODS: A national, multicenter, prospective, cross-sectional survey was conducted using responses to hypothetical patient safety scenarios involving the following: fabricating results, personal protective equipment, presenteeism, and reporting concerns.Australian enrolled medical students, medical doctors, and members of the public were surveyed.Participant responses were compared for the different contextual variables within the scenarios and the participants' demographic characteristics. RESULTS: In total, 2602 medical student, 809 doctors, and 503 members of the Australian public participated. The 3 demographic groups had significantly differing opinions on many of the patient safety dilemmas. Doctors were more tolerant of medical students not reporting concerning behaviors and attending placements despite recent illness. Medical students' opinions frequently demonstrated a "transition effect," bridging between the doctors and publics' attitudes, consistent with professional identity formation. CONCLUSIONS: Opinions on the acceptability of medical students' patient safety-related behaviors were influenced by the demographics of the cohort and the contextual complexity of the scenario. Although the survey used hypothetical scenarios, doctors and medical students' opinions seem to be influenced by cognitive dissonances, biases, and heuristics, which may negatively affect patient safety.

Why do neonates receive antiseizure medications?

BACKGROUND: Continuous conventional video-electroencephalography (cVEEG), the gold standard, is not routinely available for monitoring neonatal seizures in Australia. Therefore, seizures are monitored with clinical observation and amplitude-integrated electroencephalography (aEEG), which may result in under- or over-treatment with antiseizure medications (ASMs). We aimed to investigate ASM usage and its relation to the "cVEEG-confirmed seizures" (cVEEG seizures) in the at-risk infants admitted to a tertiary referral neonatal intensive care unit (NICU). METHODS: The study was a part of a diagnostic study comparing cVEEG with aEEG for the detection of neonatal seizures. Thirty-six infants ≥35 weeks gestational age and at risk of seizures and admitted to NICU were recruited after informed parental consent. The infants were monitored and treated with ASMs based on clinical observation and aEEG findings. A simultaneous cVEEG, not available for clinical decision making, was recorded for 24-h and interpreted at a later date. Data regarding ASM usage and seizure burden on cVEEG were collected. Spearman's Rho coefficient was used to assess the correlation between the number of doses of ASMs administered and seizure burden on cVEEG. RESULTS: cVEEG recordings of 35 infants were available for analysis. The gestational age of the infants ranged from 36 to 42 weeks, and the most common diagnosis was hypoxic-ischemic encephalopathy. Twelve infants received ASMs during the 24-h study period, of which five (42%) did not have cVEEG seizures. Maximum cVEEG seizure burden was 8.3 h, and maximum number of ASMs used was three. The correlation between the number of doses of ASMs administered in an infant and the seizure burden on cVEEG was low (Spearman's Rho: 0.44; p = .148). CONCLUSION: Treatment of neonatal seizures based on clinical observation and aEEG, without cVEEG, results in unnecessary or inadequate exposure to ASMs for many infants.

Effect of Enteral Vitamin A on Fecal Calprotectin in Extremely Preterm Infants: A Nested Prospective Observational Study.

BACKGROUND: Vitamin A has anti-inflammatory and immune-modulating properties. We aimed to assess whether enteral water-soluble vitamin A supplementation in extremely preterm infants decreases fecal calprotectin, a marker of intestinal inflammation. METHODS: This was a prospective observational study nested in a randomized, double-blind, placebo-controlled clinical trial investigating enteral vitamin A (5,000 IU/day) for reducing the severity of bronchopulmonary dysplasia (BPD) in extremely preterm infants. Fecal calprotectin levels were measured using enzyme-linked immunosorbent assay after 28 days of Vitamin A or placebo supplementation. RESULTS: Fecal calprotectin was measured in 66 infants (Vitamin A: 33, Placebo: 33). The mean (standard deviation) gestational age (25.5 [1.55] vs. 25.8 [1.48]; p = 0.341) (week), birth weight (810 [200] vs. 877 [251]; p = 0.240) (gram), and factors influencing fecal calprotectin levels were comparable between the vitamin A versus placebo group infants. All infants were exclusively fed with mother's or donor's human breast milk if mother's milk was unavailable using a standardized feeding regimen and received prophylactic probiotic supplementation. Fecal calprotectin levels (median; 25th-75th centiles) (micrograms/gram of feces) were not significantly different between vitamin A (152; 97-212) and placebo groups (179; 91-313) (p = 0.195). Two infants in the vitamin A group developed definite necrotizing enterocolitis compared to none in the placebo group. Incidence of BPD at 36 weeks postmenstrual age was similar between the groups (vitamin A: 18/33, placebo: 13/33, p = 0.218). CONCLUSION: Enteral supplementation with water-soluble vitamin A did not affect fecal calprotectin levels in extremely preterm infants. Studies with a larger sample size are required to confirm the findings.

Effect of shift work on fatigue and sleep in neonatal registrars.

OBJECTIVE: We aimed to study fatigue and sleep in registrars working 12-hour rotating shifts in our tertiary neonatal intensive unit. METHODS AND PARTICIPANTS: This study involved neonatal registrar's working day (08:00-21:00) and night (20:30-08:30) shifts. Participants maintained a sleep diary, answered a self-reported sleepiness questionnaire assessing subjective sleepiness, and performed a 10-minute psychomotor vigilance task (PVT) at the start and end of each shift. Primary outcomes: (1) Fatigue at the (i) "start vs end" of day and night shifts, (ii) end of the "day vs night" shifts, and (iii) end of "first vs last shift" in block of day and night shifts. (2) Duration and quality of sleep before the "day vs night" shifts. Mean reaction time (RTM), relative coefficient of variation (RTCV), and lapses (reaction time > 500ms) were used as measures of fatigue on PVT. Secondary outcome: Subjective sleepiness (self-reported sleepiness questionnaire) at the 'start vs end" of day and night shifts. RESULTS: Fifteen registrars completed the study. Acuity was comparable for all shifts. (1) Psychomotor responses were impaired at the end vs start of day shifts [RTM (p = 0.014), lapses (p = 0.001)], end vs start of night shifts [RTM (p = 0.007), RTCV (p = 0.003), lapses (p<0.001)] and end of night vs day shifts [RTM (p = 0.007), RTCV (p = 0.046), lapses (p = 0.001)]. Only lapses were significantly increased at the end of the last (p = 0.013) vs first shift (p = 0.009) in a block of day and night shifts. (2) Duration of sleep before the night (p = 0.019) and consecutive night shifts was decreased significantly (p = 0.034). Subjective sleepiness worsened after day (p = 0.014) and night shifts (p<0.001). CONCLUSION: Fatigue worsened after the 12-hour day and night shifts with a greater change after night shifts. Lapses increased after block of day and night shifts. Sleep was decreased before night shifts. Our findings need to be confirmed in larger studies.

Enteral Vitamin A for Reducing Severity of Bronchopulmonary Dysplasia: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Evidence suggests that intramuscular vitamin A reduces the risk of bronchopulmonary dysplasia (BPD) in preterm infants. Our objective was to compare enteral water-soluble vitamin A with placebo supplementation to reduce the severity of BPD in extremely preterm infants. METHODS: We conducted a double-blind randomized controlled trial in infants <28 weeks' gestation who were to receive either enteral water-soluble vitamin A (5000 IU per day) or a placebo. Supplementation was started within 24 hours of introduction of feeds and continued until 34 weeks' postmenstrual age (PMA). The primary outcome was the severity of BPD, assessed by using the right shift of the pulse oximeter saturation versus the inspired oxygen pressure curve. RESULTS: A total of 188 infants were randomly assigned. The mean ± SD birth weight (852 ± 201 vs 852 ± 211 g) and gestation (25.8 ± 1.49 vs 26.0 ± 1.39 weeks) were comparable between the vitamin A and placebo groups. There was no difference in the right shift (median [25th-75th percentiles]) of the pulse oximeter saturation versus inspired oxygen pressure curve (in kilopascals) between the vitamin A (11.1 [9.5-13.7]) and placebo groups (10.7 [9.5-13.1]) (P = .73). Enteral vitamin A did not affect diagnosis of BPD or other clinical outcomes. Plasma retinol levels were significantly higher in the vitamin A group versus the placebo group on day 28 and at 34 weeks' PMA. CONCLUSIONS: Enteral water-soluble vitamin A supplementation improves plasma retinol levels in extremely preterm infants but does not reduce the severity of BPD.

Effect of cumulative dexamethasone dose in preterm infants on neurodevelopmental and growth outcomes: a Western Australia experience.

OBJECTIVE: Comparing the long-term neurodevelopmental and growth outcomes of lower and higher cumulative dexamethasone exposure in preterm infants ventilated for a minimum cumulative duration of 7 days. DESIGN: A retrospective cohort medical chart review of infants born in Western Australia <29 weeks' gestation between January 2007 and May 2016 who were mechanically ventilated >7 days. INTERVENTION: No dexamethasone (controls) or a total cumulative dexamethasone dose of <2 mg/kg (lower) and ≥2 mg/kg (higher). MAIN OUTCOME MEASURES: Long-term disability at 2 and 5 years and growth measurement outcomes at 2 years of age. RESULTS: Dexamethasone was given to 104 infants (66 with cumulative dose <2 mg/kg; 38 with cumulative dose ≥2 mg/kg), and 324 infants were controls. There was no difference in odds of long-term disability in infants with any dexamethasone exposure compared with controls (aOR: 0.90, 95% CI 0.34 to 2.02, p=0.784). No difference in long-term disability was found between the lower and higher groups (p=0.494). The prevalence of cerebral palsy (Gross Motor Functional Classification System level ≥2) between the control, lower and high-dose groups did not differ significantly (5.8% vs 4.0% vs 0%). The higher dose group had lower mean weight z-score (mean effect: -0.83, 95% CI: -1.54 to -0.01, p=0.023), height z-score (mean effect: -0.63, 95% CI: -12.5 to -0.01, p=0.048) and head circumference z-score (mean effect: -0.65, 95% CI: -1.25 to -0.05, p=0.035) compared with controls. CONCLUSIONS: In our cohort, dexamethasone use was not associated with increased odds of long-term disability. Dexamethasone use was associated with lower growth measurements compared with controls.

Inter-rater reliability of amplitude-integrated EEG for the detection of neonatal seizures.

BACKGROUND: Amplitude-integrated electroencephalogram (aEEG) is being used increasingly for seizure detection in neonates. However, data regarding inter-rater reliability among neonatologists for the use of aEEG for the detection of neonatal seizures is lacking. METHODS: Term and late-preterm infants at risk of seizures were monitored simultaneously with 24-h video-electroencephalography (vEEG) and aEEG. vEEG was interpreted by an experienced neurologist. Five neonatologists with experience in aEEG interpretation from four different neonatal units interpreted aEEG recordings independently. The Brennan and Prediger kappa coefficient and Intra-class Correlation Coefficients (ICC) were used to assess inter-rater reliability between the neonatologists. RESULTS: Thirty-five infants at risk of seizure with gestational age at birth 35-42 weeks were recruited for the study after informed parental consent. vEEG detected seizures in seven infants with a total of 169 individual seizure episodes. Neonatologists detected seizures in 10 to 15 infants on aEEG. The sensitivities for the detection of individual seizures by neonatologists ranged from 18% to 38%. The inter-rater reliability for detection of: individual seizure was "fair" (kappa = 0.37; 95% CI: 0.32-0.42), infant with seizure was "moderate" (kappa = 0.60; 95% CI: 0.44-0.75), duration of individual seizure (ICC: 0.22; 95% CI: 0.18-0.28) and total duration of seizures in an infant (ICC: 0.46; 95% CI: 0.30-0.63) was "poor". The neonatologists missed 77-90% of the duration of seizures. CONCLUSION: The inter-rater reliability of aEEG for the detection of neonatal seizures was suboptimal. Even when interpreted by experienced and trained clinicians, seizure detection with aEEG has limitations and can miss large number and duration of seizures.

Developmental dysplasia of the hip in preterm breech infants.

BACKGROUND: Whether preterm infants born with breech presentation are at similar risk of developmental dysplasia of the hip (DDH) as the term breech infants is not known. The information will be vital for DDH screening guidelines. METHODS: A retrospective audit of infants born in the breech position was performed to compare the incidence of DDH in the following gestational age groups: 23-27, 28-31, 32-36 and ≥37 weeks. RESULTS: A total of 1144 neonates were included in the study. The incidence of DDH did not differ between the groups (11.6%, 9.4%, 13.6% and 11.5%, in 23-27, 28-31, 32-36 and ≥37 weeks, respectively, p=0.40). Sixty infants required intervention for DDH. Multiple logistic regression after correcting for potential confounders showed that gestational age group did not influence the risk of DDH, and requirement of therapy. CONCLUSION: Preterm infants born with breech presentation appear to have a similar incidence of DDH to term breech infants. .

A before and after study of the impact on obstetric and perinatal outcomes following the introduction of an educational package of fetal heart rate monitoring education coupled with umbilical artery lactate sampling in a low resource setting labor ward in South Africa.

INTRODUCTION: Rates of cesarean section (CS) are increasing and abnormal fetal heart rate tracing and concern about consequent acidosis remain one of the most common indications for primary CS. Umbilical artery (UA) lactate sampling provides clinicians with point of care feedback on CTG interpretation and intrapartum care and may result in altered future practice. MATERIALS AND METHODS: From 3rd March - 12th November 2014 we undertook a before and after study in Pretoria, South Africa, to determine the impact of introducing a clinical package of fetal heart rate monitoring education and prompt feedback with UA cord lactate sampling, using a hand-held meter, on maternal and perinatal outcomes. RESULTS: Nine hundred thirty-six consecutive samples were analyzed (pre n = 374 and post n = 562). There was no difference in mean lactate (4.6 mmol/L [95%CI 4.4-4.8] compared with 4.9 mmol/L [95%CI 4.7-5.1], p = 0.089). Suspected fetal compromise was reduced in the post-intervention period: 30·2% vs 22·1%, aOR 0·71, 95% CI 0·52-0·96, p = 0·027. Cesarean section rates were significantly reduced in the univariate analysis: pre- 40·3% vs post-intervention 31·6% (p = 0·007). This reduction remained significant when adjusted for previous cesarean section, primiparity, maternal HIV infection and preterm birth (aOR 0·72, 95%CI 0·54-0·98, p = 0·035). Neonatal outcomes did not differ between the two groups. CONCLUSION: The introduction of a clinical practice package of fetal heart rate monitoring education combined with routine UA cord lactate sampling has the potential to reduce the cesarean section rate without increasing adverse neonatal outcomes in a low-resource setting.

Group B streptococcus prevalence, serotype distribution and colonization dynamics in Western Australian pregnant women.

PURPOSE: Streptococcus agalactiae, or group B streptococcus (GBS), is a leading neonatal pathogen that causes sepsis, meningitis and pneumonia. Globally, strategies have been implemented to address vertical transmission, and in Western Australia (WA), culture-based screening at 35-37 weeks' gestation is part of routine care and guides antibiotic administration. Previous Australian studies have focused on other regions or included low sample-size representatives; we aimed to describe antenatal GBS colonization in WA. METHODOLOGY: A cohort of 814 pregnant women attending antenatal clinics (2015-2017) self-collected vaginal and rectal swabs at ≤22 weeks (n=814) and ≥33 weeks' (n=567) gestation. These were assessed for GBS presence using culture and PCR, and serotyping was conducted using molecular methods. Lifestyle questionnaires and medical data were collected. RESULTS: We observed an overall GBS colonization rate of 24%, with 10.6  % of positive participants transiently colonized. Ethnicity (Aboriginal, Torres Strait Islander and African), maternal age ≥25 years, vitamin use, frequent sexual intercourse (≥5 times/week) and use of sex toys were associated with GBS colonization. The dominant serotypes identified were Ia (27.9%), III (20.9%), II (16.3%), V (15.8%), Ib (8.4%), VI (5.1%), IV (2.8%), NT (1.9), VIII (0.5%) and IX (0.5%) at visit one, with V (18.9%) preceding serotype II (18.2%) at visit two. Serotype VII was not detected. CONCLUSION: This is the first cohort study to assess GBS colonization in Western Australian pregnant women and will be highly beneficial for guiding clinical practice and future therapeutic options, in particular, the selection of suitable vaccine candidates.

Long-term medical and psychosocial outcomes in congenital diaphragmatic hernia survivors.

OBJECTIVE: Survival rates for congenital diaphragmatic hernia (CDH) are increasing. The long-term outcomes of CDH survivors were compared with a healthy control group to assess the morbidity for guidance of antenatal counselling and long-term follow-up programmes. PARTICIPANTS AND DESIGN: Participants born with CDH in Western Australia 1993-2008 were eligible with matched controls from the general population. Participants had comprehensive lung function tests, echocardiogram, low-dose chest CT scan and completed a Strengths and Difficulties Questionnaire (SDQ) and quality of life (QOL) questionnaire. RESULTS: 34 matched case-control pairs were recruited. Demographic data between groups were similar. Cases were smaller at follow-up (weight Z-score of -0.2vs0.3; p=0.03; height Z-score of -0.3vs0.6; p=0.01). Cases had lower mean Z-scores for forced expiratory volume in 1 s (FEV1) (-1.49 vs -0.01; p=0.004), FEV1/forced vital capacity (-1.92 vs -1.2; p=0.009) and forced expiratory flow at 25-75% (FEF25-75) (-1.18vs0.23; p=0.007). Cases had significantly worse respiratory mechanics using forced oscillation technique. Subpleural triangles architectural distortion, linear opacities and scoliosis on chest CT were significantly higher in cases. Prosthetic patch requirement was associated with worse lung mechanics and peak cough flow. Cases had significantly higher rates of gastro-oesophageal reflux disease (GORD) and GORD medication usage. Developmental delay was significantly higher in cases. More cases had a total difficulties score in the high to very high range (25% vs 0%, p=0.03) on the SDQ and reported lower objective QOL scores (70.2 vs 79.8, p=0.02). CONCLUSION: Survivors of CDH may have significant adverse long-term medical and psychosocial issues that would be better recognised and managed in a multidisciplinary clinic.

High frequency jet ventilation in preterm infants: experience from Western Australia.

Objective: To assess if high frequency jet ventilation (HFJV) is associated with reduced odds of death or discharge home on oxygen in preterm infants. Methods: A case control study (1 February 2010 - 1 June 2014) comparing the primary outcome as "death or discharge home on oxygen" in preterm infants who needed HFJV (Cases) versus those who did not (Controls). Controls were matched to cases (1:1) on gestation, birthweight, gender, place of birth, growth status, antenatal glucocorticoids, and dexamethasone as treatment for severe bronchopulmonary dysplasia (BPD). Logistic regression analysis was used to control for confounders. Results: Data on all preterm infants who needed HFJV (Cases: n = 50) and 50 controls during the study period were analysed. Primary outcome was more frequent in cases versus controls, but not significant after adjusting for mean airway pressure and adjuvant therapy (e.g. diuretics) [aOR: 1.46 (0.23-9.14), p = .687]. Death before discharge [odds ratios (OR): 6.00 (1.34-55.2), p = .013] was more frequent in cases; discharge on home oxygen [OR: 0.88 (0.27-2.76), p = 1.000] was comparable between groups. Duration of oxygen [adjusted hazard ratios (aHR): 1.23 (0.69-2.17), p = .475] and incidence of treatment warranting retinopathy of prematurity [aOR: 0.10 (0.01-1.96), p = .127] was not significant between cases versus controls. Conclusions: HFJV was not associated with reduced odds of death or discharge home on oxygen in preterm infants in our study. Adequately powered randomized trials are required to assess the efficacy and safety of HFJV in preterm infants.

Impact of maternal HIV on umbilical cord lactate measurement at delivery in a South African labor ward.

OBJECTIVE: To assess umbilical artery lactate levels and perinatal outcomes among women with and without HIV infection. METHODS: The present prospective cohort study recruited women planning to undergo vaginal delivery at Kalafong Hospital, South Africa, between March 3 and November 12, 2014. Umbilical artery lactate levels were measured and perinatal outcome data were recorded. Outcome analyses were stratified by maternal HIV status, and a subgroup analysis was performed where women with a CD4 count below 350 × 106 cells/L were compared with women without HIV. RESULTS: In total, 936 women with singleton fetuses were enrolled. Maternal HIV status was available for 897 (95.8%) participants, of whom 202 (21.6%) had HIV infections. Overall, 186 (92.1%) women with HIV infections received prophylaxis or treatment. There was no difference between participants with and without HIV infections in the preterm delivery rate (P=0.770), mode of delivery (P=0.354), neonatal resuscitation rate (P=0.717), 1- or 5-minute Apgar scores below 7 (P=0.353), or the rate of having an umbilical artery lactate level above 5.45 mmol/L (P=0.301). Similarly, there were no differences in outcomes in the subgroup analysis of women with a CD4 count below 350 × 106 cells/L. CONCLUSION: Umbilical artery lactate levels and perinatal outcomes were found to be comparable between patients with and without HIV infections in a South African setting.

Severe acquired subglottic stenosis in neonatal intensive care graduates: a case-control study.

OBJECTIVE: To analyse current incidence and risk factors associated with severe acquired subglottic stenosis (SASGS) requiring surgical intervention in neonates. DESIGN: Retrospective case-control study. SETTING: Sole tertiary children's hospital. PARTICIPANTS: Patients who underwent surgical intervention for SASGS from January 2006 to December 2014. For each neonatal intensive care unit (NICU) graduate with acquired SASGS, two controls were selected (matched for gestation and year of birth). MAIN OUTCOMES AND MEASURES: Incidences were calculated and cases and controls compared using conditional logistic regression analysis to identify risk factors for SASGS. RESULTS: Thirty-seven NICU graduates required surgical intervention for SASGS of whom 35 were <30-week gestation at birth. The incidence of SASGS in surviving children who had required ventilation in the neonatal period was 27/2913 (0.93%). Incidence was higher in infants <28-week gestation (24/623=3.8%) compared with infants ≥28-week gestation (3/2290=0.13%; p=0.0001). On univariate analysis, risk factors for SASGS were: higher number of intubations (4 vs 2; p<0.001); longer duration ventilation (16 vs 9.5 days; p<0.001); unplanned extubation (45.7% vs 20.0%; p=0.007); traumatic intubation (34.3% vs 7.1%; p=0.003) and oversized endotracheal tubes (ETTs) (74.3% vs 42.9%; p=0.001). On multivariate analysis, risk factors for SASGS were: Sherman ratio >0.1 (adjusted OR (aOR) 6.40; 95% CI 1.65 to 24.77); more than five previous intubations (aOR 3.74; 95% CI 1.15 to 12.19); traumatic intubation (aOR 3.37; 95% CI 1.01 to 11.26). CONCLUSIONS: SASGS is a serious consequence of intubation for mechanical ventilation in NICU graduates, especially in preterm infants. Minimising trauma during intubations, avoiding recurrent extubation/reintubations and using appropriate sized ETTs may help prevent this serious complication.

Minimising compassion fatigue in obstetrics/gynaecology doctors: exploring an intervention for an occupational hazard.

AIM: To explore the indicators of occupational stress in a group of obstetrics and gynaecology doctors and to investigate the impact of work-focused discussion groups over a 6 month period. METHODS: The ProQOL questionnaire was used to measure the efficacy of monthly psychiatrist-led Balint style discussion groups on minimising Compassion Fatigue (consisting of Secondary Traumatic Stress and Burnout). The 25 doctors were given the given the ProQOL questionnaire to complete: (a) at the initiation of the intervention in July 2015, (b) in October 2015, and (c) in December 2015. RESULTS: Significantly decreased levels of Secondary Traumatic Stress ( p=0.008), Burnout ( p=0.010), as well as significantly increased rates of Compassion Satisfaction ( p=0.035) were recorded. Participants requested that the groups be continued. CONCLUSIONS: Psychiatrist-led work focused discussion groups were associated with improved rates of Secondary Traumatic Stress, Burnout, and Compassion Satisfaction in this sample group.

Preclinical evaluation of drugs to block inflammation-driven preterm birth.

Intrauterine inflammation, the major cause of early preterm birth, can have microbial and sterile aetiologies. We assessed in a Transwell model the anti-inflammatory efficacies of five drugs on human extraplacental membranes delivered after preterm spontaneous labour (30-34 wk). Drugs [TPCA1 (IKKß inhibitor), 5 z-7-oxozeaenol (OxZ, TAK1 inhibitor), inhibitor of NF-κB essential modulator binding domain (iNBD), SB239063 (p38 MAPK inhibitor) and N-acetyl cysteine (free radical scavenger free radicals)] were added after 12 h equilibration to the amniotic compartment. Concentrations of IL-6, TNF-α, MCP-1, IL-1ß and PGE2 in the media, and IL6, TNFA and PTGS2 mRNA expression levels in membranes, were determined after 12 h. Data were analysed using mixed models analyses. Thirteen of the 28 membranes had histological chorioamnionitis (HCA+); five were positive for bacterial culture and six for fetal inflammatory reaction. Baseline PGE2 and cytokine production was similar between HCA- and HCA+ membranes. Anti-inflammatory effects were also similar between HCA- and HCA+ membranes. TPCA1 and OxZ were the most effective drugs; each inhibited amniotic secretion of 4/5 pro-inflammatory mediators and mRNA levels of 2/3, regardless of stimulus. We conclude that treatment with TPCA1 or OxZ, in combination with antibiotics, may minimise the adverse effects of intrauterine inflammation in pregnancy.