The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention.

BACKGROUND: Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes. METHODS: A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation. DISCUSSION: The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources. TRIAL REGISTRATION: ClinicalTrials.gov, NCT0522662. Registered February 4th, 2022.

Fostering Hope: Comprehensive Accessible Mother-Infant Dyad Care for Neonatal Abstinence (CAIN).

Hospital and community healthcare providers have expressed concerns around the continuity and quality of care for infants with neonatal abstinence syndrome (NAS) during hospitalization and transition home. This qualitative study explored the experiences of hospital and community-based healthcare providers and identified themes related to the management of NAS for mothers and infants. Healthcare providers that cared for women with substance use disorders and/or cared for newborns with NAS in a large urban setting in Canada met inclusion criteria for this study and were interviewed in groups or as individuals. Interview transcripts were reviewed iteratively using inductive thematic analysis to identify an overarching theme linked with primary themes. In total, 45 healthcare providers were interviewed. Qualitative analysis of their experiences derived the overarching theme of hope with five primary themes being: mother/infant, mental health, system, judgement, and knowledge. The study identified gaps in NAS care including fear, stigma, and language. This research demonstrates that programs and interventions that work with mothers and newborns with NAS must foster hope in mothers, families, and in the extended care provider team and improve communication between hospital and community networks.

Implementation of the Neonatal Nurse Practitioner Role in a Community Hospital's Labor, Delivery, and Level 1 Postpartum Unit.

BACKGROUND: A level 1 community hospital with a labor, delivery, recovery, and postpartum (LDRP) unit delivering over 2800 babies per year was operating without dedicated neonatal resuscitation and stabilization support. PURPOSE: With lack of funding and space to provide an onsite level 2 neonatal intensive care unit (NICU), a position was created to provide neonatal nurse practitioner (NNP) coverage to support the LDRP unit. METHOD: The article describes the innovative solution of having an NNP team rotate from a regional neonatal intensive care program to a busy community LDRP unit. The presence of the NNP supported the development and integration of the advanced practice nursing role with interdisciplinary team members in both the LDRP and the emergency department. RESULTS: The NNP was able to provide expertise, leadership, and mentorship for neonatal resuscitation and stabilization as well as education and consultation on neonatal care. In addition to the services provided by the NNP for infant's requiring acute care, the NNP provided transitional support for those infants who remained with their mothers in the LDRP unit. Furthermore, time required by the neonatal transport team to stabilize babies before transport to the NICU was decreased with NNP presence. IMPLICATIONS FOR PRACTICE: The divergence from practice of the traditional NNP clinical role in the NICU setting to more of a consultant and nursing leader has proven to be a valued role at the community hospital. IMPLICATIONS FOR RESEARCH: A solid economic analysis of the cost-effectiveness of the NNP role in this community hospital is warranted.

Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea.

STUDY OBJECTIVE: To determine the impact of continuous positive airway pressure (CPAP) on weight change in persons with obstructive sleep apnea (OSA). DESIGN SETTING AND PARTICIPANTS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) was a 6-month, randomized, double-blinded sham-controlled multicenter clinical trial conducted at 5 sites in the United States. Of 1,105 participants with an apnea hypopnea index ≥ 10 events/ hour initially randomized, 812 had body weight measured at baseline and after 6 months of study. INTERVENTION: CPAP or Sham CPAP. MEASUREMENTS: Body weight, height, hours of CPAP or Sham CPAP use, Epworth Sleepiness Scale score. RESULTS: Participants randomized to CPAP gained 0.35 ± 5.01 kg, whereas those on Sham CPAP lost 0.70 ± 4.03 kg (mean ± SD, p = 0.001). Amount of weight gain with CPAP was related to hours of device adherence, with each hour per night of use predicting a 0.42 kg increase in weight. This association was not noted in the Sham CPAP group. CPAP participants who used their device ≥ 4 h per night on ≥ 70% of nights gained the most weight over 6 months in comparison to non-adherent CPAP participants (1.0 ± 5.3 vs. -0.3 ± 5.0 kg, p = 0.014). CONCLUSIONS: OSA patients using CPAP may gain a modest amount of weight with the greatest weight gain found in those most compliant with CPAP. COMMENTARY: A commentary on this article appears in this issue on page 995. CITATION: Quan SF; Budhiraja R; Clarke DP; Goodwin JL; Gottlieb DJ; Nichols DA; Simon RD; Smith TW; Walsh JK; Kushida CA. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea.

Resurgence of congenital syphilis: diagnosis and treatment.

Despite comprehensive antenatal screening recommendations and inexpensive treatment, congenital syphilis has long been and continues to be a public health concern, causing substantial morbidity and adverse outcomes. The following article reviews syphilis etiology and presentation, clinical disease, laboratory diagnosis, and treatment of congenital syphilis. A case will be presented describing a 31-week male infant exposed to infectious syphilis in utero. The neonate presented with classic signs of infection at birth. After initial serology testing of the infant, appropriate treatment was commenced. The infant received crystalline penicillin G for a period of ten days in consultation with pediatric infectious disease specialists. As expected, the infant's rapid plasma reagin (RPR) titers declined by three and six months of age. An interdisciplinary approach provided safe and optimal care for this infant. He was discharged, stable, and thriving at 38 weeks corrected age. Long-term multidisciplinary management and follow-up were arranged.

Management and outcome of positive urine cultures in a neonatal intensive care unit.

OBJECTIVES: The aim of this study was to describe the management and outcome of positive urine cultures in a neonatal intensive care unit (NICU). STUDY DESIGN: A chart review was completed of infants born October 1, 2004 to December 31, 2006 and admitted to the NICU at the Royal Alexandra Hospital, Edmonton, Alberta with any growth of bacteria or fungi in urine. RESULTS: Positive urine cultures were obtained in 64 of 2936 admissions (2%) and were classified as contaminated urines (n=34), possible urinary tract infection (UTI) (n=14), definite UTI (n=10), and candidal UTI (n=6). Management was inconsistent. Two children required new assisted ventilation but no other complications occurred. CONCLUSIONS: The diagnosis of UTI in NICU is hampered by use of urine collection methods that are subject to contamination. Outcome is generally excellent, but there is a great need for guidelines on management of positive urine cultures in the NICU.

Evaluation of methods for rapid detection of resistance to isoniazid and rifampin in Mycobacterium tuberculosis isolates collected in the Caribbean.

The rapid identification of drug-resistant strains of Mycobacterium tuberculosis is crucial for the timely initiation of appropriate antituberculosis therapy. The performance of the Genotype MTBDRplus assay was compared with that of the Bactec 460 TB system, a "gold standard" culture-based method. The Genotype MTBDRplus assay was quicker and more cost-effective for the detection of rifampin resistance, but it was not as good for the detection of isoniazid-resistant strains in our setting.

Evaluation of methods for rapid detection of resistance to isoniazid and rifampin in Mycobacterium tuberculosis isolates collected in the Caribbean.

The rapid identification of drug-resistant strains of Mycobacterium tuberculosis is crucial for the timely initiation of appropriate antituberculosis therapy. The performance of the Genotype MTBDRplus assay was compared with that of the Bactec 460 TB system, a "gold standard" culture-based method. The Genotype MTBDRplus assay was quicker and more cost-effective for the detection of rifampin resistance, but it was not as good for the detection of isoniazid-resistant strains in our setting.

Sleep quality deteriorates over a binge--abstinence cycle in chronic smoked cocaine users.

RATIONALE: In cocaine dependent individuals, changes in subjective and objective sleep quality accompany their characteristic binge-abstinence cycle. Preliminary studies suggest that sleep quality may decline with prolonged abstinence. Reported here are results of the most extensive study to date on sleep abnormalities during cocaine binge and confirmed abstinence under controlled conditions. OBJECTIVES: The purpose of the current study was to use an experimental, inpatient model of the cocaine binge and abstinence cycle to examine the course and magnitude of sleep disturbances during cocaine use and abstinence. METHODS: Five inpatient non-treatment seeking cocaine users completed 3 baseline days of drug abstinence followed by 3 days of medically monitored "binge" cocaine use, and then 15 days of drug abstinence. Physiological sleep was recorded with polysomnography and the Nightcap ambulatory monitor, while subjective sleep was assessed by questionnaire. RESULTS: Across 3 days of binge cocaine use and 15 subsequent days of confirmed drug abstinence, mean sleep duration, efficiency and latency changed in the direction of poorer sleep quality. In contrast, subjective reports of sleep quality remained unchanged across the same period. CONCLUSIONS: Physiological sleep quality deteriorated from days when cocaine was used across the first 2 weeks of confirmed drug abstinence. In contrast, subjective reports of sleep quality remained unchanged across the same period. We postulate that this dissociation between objective and subjective sleep quality results from a cocaine-use related disruption of the sleep homeostat. Worsening sleep quality during cocaine abstinence may contribute to the risk of relapse and its treatment may offer novel therapeutic strategies for cocaine dependence.

Re-emergence of tuberculosis in the Caribbean: how ready are the Caribbean laboratories in 1997

WHO declared tuberculosis a "Global Emergency" in 1994. The incidence of tuberculosis is increasing in the English speaking Caribbean. Sporadic occurrence of multiple drug resistance M. tuberculosis has been reported in a few countries in this region. It is well recognized that the laboratory plays an important role in the control of tuberculosis through rapid detection, isolation, idenfification of and drug susceptibility testing of M. tuberculosis. Twenty one laboratories were surveyed to assess the current practices and capabilities that exist in laboratories for the detection isolation and drug susceptibility testing of M. tuberculosis in the Caribbean. Sixteen laboratories perform laboratory diagnosis of tuberculosis. Microscopic examination of sputum for acid fast bacilli (AFB) is being performed in 12 laboratories by the direct method. The most commonly used method is the Kinyoun technique (10/16). Only one laboratory is practising fluorochrome methods for the rapid detection of AFB in sputum and other clinical specimens. Only five laboratories culture for mycobacteria. None of the laboratories perform either nucleic acid probes or BACTEC NAP for the identification of mycobacteriae other than tuberculosis (MOTT). Only three laboratories perform antimicrobial susceptibility testing in the Caribbean. All susceptibility testing for M. tuberculosis is done on solid media (LJ slants). The major antibiotics test are rifampicin, isoniazid, ethambutol and stretomycin. Sixty three percent of laboratories do not have a policy on monitoring of laboratory personnel by tuberculosis testing. The use of disposable bacteriological loops and bacticinerator as a minimal safety procedure is 57 percent and 63 percent respectively. Centrifuges with safety carriers are being used in only 13 percent of laboratories. Eight laboratories (50 percent) use Level 2 containment biological safety cabinet while processing of all specimens for mycobacterial infections. Reporting of smear results to hospital, physician or the ministry of health/public health department is mainly done by telephone; but some laboratories report by writing and telephone. Thirty seven percent (6/16) laboratories do not report positive smear AFB results to the public health department. The time required to report AFB smear microscopy results take on an average of over 48 hrs in 75 percent of laboratories.

Re-emergence of tuberculosis in the Caribbean: how ready are the Caribbean laboratories in 1997

WHO declared tuberculosis a "Global Emergency" in 1994. The incidence of tuberculosis is increasing in the English speaking Caribbean. Sporadic occurrence of multiple drug resistance M. tuberculosis has been reported in a few countries in this region. It is well recognized that the laboratory plays an important role in the control of tuberculosis through rapid detection, isolation, idenfification of and drug susceptibility testing of M. tuberculosis. Twenty one laboratories were surveyed to assess the current practices and capabilities that exist in laboratories for the detection isolation and drug susceptibility testing of M. tuberculosis in the Caribbean. Sixteen laboratories perform laboratory diagnosis of tuberculosis. Microscopic examination of sputum for acid fast bacilli (AFB) is being performed in 12 laboratories by the direct method. The most commonly used method is the Kinyoun technique (10/16). Only one laboratory is practising fluorochrome methods for the rapid detection of AFB in sputum and other clinical specimens. Only five laboratories culture for mycobacteria. None of the laboratories perform either nucleic acid probes or BACTEC NAP for the identification of mycobacteriae other than tuberculosis (MOTT). Only three laboratories perform antimicrobial susceptibility testing in the Caribbean. All susceptibility testing for M. tuberculosis is done on solid media (LJ slants). The major antibiotics test are rifampicin, isoniazid, ethambutol and stretomycin. Sixty three percent of laboratories do not have a policy on monitoring of laboratory personnel by tuberculosis testing. The use of disposable bacteriological loops and bacticinerator as a minimal safety procedure is 57 percent and 63 percent respectively. Centrifuges with safety carriers are being used in only 13 percent of laboratories. Eight laboratories (50 percent) use Level 2 containment biological safety cabinet while processing of all specimens for mycobacterial infections. Reporting of smear results to hospital, physician or the ministry of health/public health department is mainly done by telephone; but some laboratories report by writing and telephone. Thirty seven percent (6/16) laboratories do not report positive smear AFB results to the public health department. The time required to report AFB smear microscopy results take on an average of over 48 hrs in 75 percent of laboratories