The implementation and evaluation of a mentoring program for Bachelor of Midwifery students in the clinical practice environment.

AIM: To describe the implementation and evaluation of a midwife/midwifery student-mentoring program in one Local Health District in Sydney NSW Australia. BACKGROUND: Evidence suggests well designed and supported midwife/midwifery student mentorship programs can make a difference to the clinical placement experiences and attrition rates of midwifery students. DESIGN: In the evaluation of the mentoring program, we used surveys, focus groups and individual interviews. METHODS: Eighty-six participants, including midwife mentors, midwifery students, non-mentor midwives and midwifery managers participated in the evaluation. Quantitative data were analysed using descriptive statistics and qualitative data, content analysis. RESULTS: The mentoring program increased midwives' mentoring skills and was beneficial to their professional growth and leadership skills. Students reported positive outcomes including someone to talk to, emotional support and a sense of belonging. Mentoring programs require structure, mentor training, organisational support and transparency. CONCLUSION: The mentoring program provided benefits to both midwifery mentors and students and demonstrated the value of a structured and supported mentoring program for midwifery students.

A national survey of Australian midwives' birth choices and outcomes.

BACKGROUND: Maternity care in Australia is predominantly provided by midwives, many who give birth. There is a paucity of research on midwives' own childbearing preferences and experiences. AIM: To explore midwives childbirth preferences and outcomes when giving birth to their first child in Australia, after qualifying as a midwife. METHODS: An online national survey. Data were analysed using descriptive statistics. FINDINGS: 447 midwives responded, with the majority of midwives indicating a preference for a normal vaginal birth with a known care provider under a continuity of midwifery care model. For midwives who were first time mothers, 66% had normal vaginal births, 16.3% had an instrumental birth, and 16.8% had caesarean births. Over 85% of midwives received the model of care they wanted and 45% had continuity of midwifery care. While a quarter of midwives wanted a homebirth,11.2% achieved this. Over three quarters (75.4%) of midwives were cared for by a care provider of their choosing. DISCUSSION: There was a difference in models of care accessed and birth outcomes between midwives and other women giving birth for the first-time in Australia. Australian midwives appear to have the advantage of clinical and scientific knowledge to navigate the maternity care system to get the birth care and outcomes they want. CONCLUSION: It is possible that professional experience, insider knowledge, and existing relationships with other midwifery friends and colleagues, affords midwives a higher degree of agency and autonomy when it comes to getting the maternity care and birth outcomes that they want.

A mixed methods evaluation of Multiple Mini Interviews for entry into the Bachelor of Midwifery.

BACKGROUND: Multiple-mini interviews (MMI) are increasingly used as part of the admission process into healthcare degrees. Evaluations have found MMIs to be a fair assessment tool in terms of reliability and validity and viewed positively by those involved in the MMI process. The use of MMIs in midwifery is novel and evaluation is lacking. AIM: To evaluate the use of MMIs as part of the admission process for the Bachelor of Midwifery in one Australian university. METHODS: A basic convergent mixed methods study design was utilised. Data included linked data sets, Likert scale responses to survey questions, focus groups and open-ended survey questions. Integration took place at the interpretation and reporting stage. FINDINGS: Participants viewed the MMI experience positively. The study confirmed the reliability of the MMIs as an assessment tool. Most variance in MMI scores was attributed to the candidate at 31.4 % with the interviewer and the interview station having less influence on the MMI score at 11 % and 6.4 % variance. Older applicants on average achieved higher MMI scores, and those who spoke a language other than English at home or were first in family to attend university had lower on average MMI scores. Being born overseas did not impact an applicant's MMI score. The overall experience was seen as fair, offering further opportunity to gain entry into the Bachelor of Midwifery. CONCLUSION: MMIs were viewed positively and findings support the use of MMIs as part of an admissions process for the Bachelor of Midwifery.

Insider knowledge as a double-edged sword: an integrative review of midwives' personal childbearing experiences.

BACKGROUND: The majority of maternity care is provided by female midwives who have either become mothers or are of childbearing age, but there is limited research exploring midwives' own personal childbearing experiences. This integrative review aims to explore the published literature and research on midwives' own experiences of pregnancy and childbirth. METHOD: An integrative review of the literature was conducted after relevant articles were identified through a search of: five electronic databases (Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar), cited reference lists, and networking with peers. Similar and contrasting patterns and relations within the literature were identified and grouped into themes and subthemes. RESULTS: Twenty articles were included in the review and four overarching themes were identified. Insider knowledge plays a role in decision making encompassed the way midwives used their knowledge to choose; a preferred mode of birth, maternity care provider, model of care, and place of birth. Navigating the childbirth journey demonstrated how some midwives were able to use their insider knowledge to achieve agency, while others had difficulty achieving agency. This theme also revealed the 'midwife brain' that midwives need to manage during their childbearing journey. The theme impact of care on the birth experience described how the type of care the midwives received from maternity care providers affected their overall birth experience. The fourth theme from midwife to mother explains their preparedness for childbirth and their transition to motherhood. CONCLUSION: For childbearing midwives, there is a potential conflict between their position as knowledgeable experts in maternity care, and their experience as mothers. Whilst they can use their insider knowledge to their advantage, they also experience heightened fear and anxiety through their pregnancy. It is important for maternity care providers to acknowledge and support them and provide balanced and tailored care that acknowledges the woman within the professional midwife and the professional midwife within the woman.

The midwife-student mentor relationship: Creating the virtuous circle.

BACKGROUND: Good mentoring is important for students to support their adjustment to and learning in the clinical environment. The quality of the mentoring relationship is key for students but there is a lack of evidence explaining how a good mentor/mentee relationship establishes and develops over time. AIM: To explore the developing relationship between mentors and mentees participating in a structured midwifery mentoring program in one Local Health District in Sydney, Australia. METHODS: A qualitative interpretive descriptive research design was utilised. Data were collected using 10 focus groups with midwife mentors (n = 31) and seven focus groups and four interviews with Bachelor of Midwifery student mentees (n = 24), over a 12-month period. Thematic analysis using an inductive approach was applied incorporating constant comparison to identify themes and sub-themes. FINDINGS: Three overarching themes and three sub-themes were identified. The first theme was 'The great unknown'. Within the second theme 'Building the relationship' were three subthemes: trying to connect; becoming known; and an insider on your side. The final theme 'the virtuous circle' described the reciprocal relationship and benefits that developed between mentor and mentee. DISCUSSION: The mentor/mentee relationship took time to develop and went through a number of phases. A positive mentor/ mentee relationship flattened hierarchical differences, increased student confidence and capacity for learning, and reflected the midwifery continuity of care relationship between midwife and woman built on respect and partnership. CONCLUSION: Developing a successful midwifery mentoring relationship takes persistence, reassurance, and mutual disclosure ultimately resulting in a recurring cycle of encouragement and support.

The impact of Multiple Mini Interviews on the attrition and academic outcomes of midwifery students.

BACKGROUND: Admission to the Bachelor of Midwifery (BMid) in Australia has traditionally been based on academic ranking. The BMid is a high demand course offered to a limited number of students and therefore choosing applicants who complete the degree is important. Multiple Mini Interviews (MMIs) are used to assess non-cognitive skills and select students into healthcare degrees. One university in Australia has introduced MMIs as part of the application process for the BMid. AIM: Compare attrition rates and Grade Point Average (GPA) scores between students admitted into the BMid using both academic ranking and MMIs, to those admitted on academic ranking alone. METHODS: A basic convergent mixed methods design, using an explanatory unidirectional framework to integrate data. Attrition rates, GPA, and multiple mini interview scores (2013-2019), were linked and compared for before and after the use of MMI's. Focus groups with students, interviewers, and hospital-based educators, explored stakeholder experiences. Open-ended questions from an applicant survey were added to the qualitative data set, which was analysed thematically. FINDINGS: Students who enrolled via the MMI's had significantly lower attrition rates than those enrolled before MMI's were introduced. GPA scores were significantly higher for students who enrolled via the MMI's. Integration of data found MMI's identified students passionate to undertake midwifery, and that success at the interviews increased students' confidence to successfully complete their studies. CONCLUSION: MMI's as part of the entry process into the BMid enabled identification of applicants more likely to remain in the course and succeed in their studies.

Development of a 22q11DS psycho-educational programme: exploration of the views, concerns and educational needs of parents caring for children or adolescents with 22q11DS in relation to mental health issues.

BACKGROUND: 22q11.2 deletion syndrome (22q11DS) is a multisystem genetic condition with a broad phenotype. It is associated with a high prevalence of depression and anxiety during childhood and increased risk of schizophrenia in adulthood. Despite this, studies report that families may receive inadequate information of mental health (MH) risks at diagnosis. Therefore, this study investigated parents' experiences of caring for a child with 22q11DS, investigated their knowledge regarding the risk of MH problems and assessed the need for a psycho-educational programme. METHODS: A qualitative design and purposeful sampling was utilized. Parents registered with the '22q11 Ireland' support group, and parents listed on the cleft palate database in a children's hospital in Ireland were invited to participate. Focus groups were held with 22 parents. Data were thematically analysed using Burnard's method of analysis. RESULTS: Most parents had some knowledge of the relationship between 22q11DS and an increased risk of MH issues. Parents reported that MH information relating to 22q11DS was mainly obtained from 22q11DS conferences, the '22q11 Ireland' support group and the Internet. Parents expressed a need for information to prevent or cope with their child's MH issues. Parents suggested that the following topics would be quite useful in a psycho-educational programme. These included information on the early warning signs of MH issues and guidance on when and how to tell the child about the condition and how to manage the child or young person's anxiety, obsessive behaviour or hearing voices. CONCLUSIONS: The findings indicated parental support for a psycho-educational programme that would provide relevant, accurate and timely information on how to effectively care for a child with 22q11DS MH needs.

Health-related quality of life of young people with long-term illnesses before and after transfer from child to adult healthcare.

BACKGROUND: The numbers of children with long-term illnesses surviving into adulthood and transferring from child to adult services has increased dramatically in the last 30 years. This study aimed to examine health-related quality of life pre- and post-transfer from child to adult healthcare for young people with three long-term illnesses. METHODS: A total of 217 young people with cystic fibrosis, congenital heart defects or diabetes attending child and adult hospital services in Dublin, Ireland completed a questionnaire survey. Multiple linear regression was used to identify predictors of five dimensions of health-related quality of life pre- and post-transfer. RESULTS: Post-transfer young people with congenital heart disease and diabetes reported significantly lower physical well-being than their pre-transfer counterparts. Pre-transfer young people with cystic fibrosis reported significantly lower physical well-being than those with diabetes, but there was no significant difference post-transfer. Pre-transfer females reported lower scores than males on the Psychological Well-being and Autonomy and Parent Relation dimensions; however, these differences disappeared post-transfer. Higher maternal overprotection scores were associated with significantly lower scores on the Psychological Well-being, Autonomy and Parent Relation, and Social Support and Peers dimensions, regardless of transfer status. CONCLUSIONS: Disease group, gender and maternal overprotection were predictors of health-related quality of life pre- and post-transfer from child to adult healthcare. Transition programmes should promote self-management and discourage parental overprotection.

An e-health intervention to support the transition of young people with long-term illnesses to adult healthcare services: Design and early use.

OBJECTIVE: Co-design information and website to support adolescents and young adults with long-term illnesses in their transition to adult healthcare. METHODS: A participatory iterative process involving a survey (n=207), twenty-one interviews, six participatory workshops, six video recordings, two advisory groups, and a co-design group to identify needs and preferences for e-health and information provision, was used to develop an appropriate intervention. RESULTS: Adolescents and young people expressed preferences for information that was trustworthy, empowering, colorful, easily downloaded online and written using non-patronizing language. They desired video testimonials of experiences from young adults who had transitioned to adult healthcare and wanted advice about becoming more independent, managing their condition, preparing for the transition, and information about medications and the differences between child and adult healthcare. They also wanted information about the location and configuration of adult healthcare, key hospital personnel, and frequently asked questions. CONCLUSION: The participatory iterative process led to the development of an online resource specifically tailored to the adolescents and young people's transition needs and information preferences. Preliminary feedback indicates that it is a valued resource. PRACTICE IMPLICATIONS: The www.SteppingUP.ie website has the potential to help prepare its target population group for the transition to adult healthcare.

The experiences and impact of transition from child to adult healthcare services for young people with Type 1 diabetes: a systematic review.

INTRODUCTION: Despite the transition between child and adult services for young people with Type 1 diabetes mellitus being a high-risk period, little is known about the impact of healthcare transition upon young people. METHODS: A systematic review was conducted using PubMed, PsycINFO, CINAHL and EMBASE. Papers published between January 2001 and June 2014 that examined the impact or experiences of healthcare transition in young people with Type 1 diabetes were included. Data were extracted by two independent reviewers and integrated by narrative synthesis. RESULTS: A total of 8990 citations were reviewed and 43 studies were included in the review, 24 of which explored the impact of transition and 24 examined experiences of transition. There were mixed results in terms of the change in glycaemic control and diabetes-related hospitalizations, but all studies assessing attendance found worse attendance post-transition. Data regarding experiences reported that young people and parents experienced greater difficulty in accessing and maintaining diabetes health care. Young people were required to develop independent self-management and self-advocacy skills to navigate the transition and adult health care, but some were inadequately prepared for this. CONCLUSIONS: Although the impact of healthcare transition on outcomes for young people with Type 1 diabetes is unclear due to the paucity of high-quality studies, transition appears to be associated with decreased clinic attendance. There is some preliminary evidence of a positive impact of structured transition programmes. Experiences of healthcare transition illuminate the barriers to smooth transitions and the need for better integration and continuity of care.

Liquid gold from the milk bar: constructions of breastmilk and breastfeeding women in the language and practices of midwives.

Midwives are the main health professional group providing support and assistance to women during the early establishment of breastfeeding. In published accounts of early breastfeeding experiences women report high levels of dissatisfaction with health professional support. To gain an understanding of this dissatisfaction, we examined the way in which midwives represent breastmilk and construct breastfeeding women in their interactions. Seventy seven women and seventy six midwives at two maternity units in NSW, Australia, participated in this study. Eighty five interactions between a midwife and a breastfeeding woman were observed and audio recorded during the first week after birth. In addition, data were collected through observation of nine parenting education sessions, interviews with 23 women following discharge, and 11 managers and lactation consultants (collected between October 2008 and September 2009). Discourse analysis was used to analyse the transcribed interactions, and interview data. The analysis revealed that midwives prioritised both colostrum and mature breastmilk as a 'precious resource', essential for the health and wellbeing of the infant and mother. References to breastmilk as 'liquid gold' were both verbal and implied. Within this discourse, the production and acquisition of 'liquid gold' appeared to be privileged over the process of breastfeeding and women were, at times, positioned as incompetent operators of their bodily 'equipment', lacking knowledge and skill in breastfeeding. In this context breastfeeding became constructed as a manufacturing process for a demanding consumer. The approach taken by midwives revealed an intensive focus on nutrition to the exclusion of relational communication and support. The findings indicate the need to challenge the current 'disciplinary' and 'technological' practices used by midwives when providing breastfeeding support and the need for a cultural change in postnatal care.

Dissection of the IgNAR V domain: molecular scanning and orthologue database mining define novel IgNAR hallmarks and affinity maturation mechanisms.

The shark antigen-binding V(NAR) domain has the potential to provide an attractive alternative to traditional biotherapeutics based on its small size, advantageous physiochemical properties, and unusual ability to target clefts in enzymes or cell surface molecules. The V(NAR) shares many of the properties of the well-characterised single-domain camelid V(H)H but is much less understood at the molecular level. We chose the hen-egg-lysozyme-specific archetypal Type I V(NAR) 5A7 and used ribosome display in combination with error-prone mutagenesis to interrogate the entire sequence space. We found a high level of mutational plasticity across the V(NAR) domain, particularly within the framework 2 and hypervariable region 2 regions. A number of residues important for affinity were identified, and a triple mutant combining A1D, S61R, and G62R resulted in a K(D) of 460 pM for hen egg lysozyme, a 20-fold improvement over wild-type 5A7, and the highest K(D) yet reported for V(NAR)-antigen interactions. These findings were rationalised using structural modelling and indicate the importance of residues outside the classical complementarity determining regions in making novel antigen contacts that modulate affinity. We also located two solvent-exposed residues (G15 and G42), distant from the V(NAR) paratope, which retain function upon mutation to cysteine and have the potential to be exploited as sites for targeted covalent modification. Our findings with 5A7 were extended to all known NAR structures using an in-depth bioinformatic analysis of sequence data available in the literature and a newly generated V(NAR) database. This study allowed us to identify, for the first time, both V(NAR)-specific and V(NAR)/Ig V(L)/TCR V(alpha) overlapping hallmark residues, which are critical for the structural and functional integrity of the single domain. Intriguingly, each of our designated V(NAR)-specific hallmarks align precisely with previously defined mutational 'cold spots' in natural nurse shark cDNA sequences. These findings will aid future V(NAR) engineering and optimisation studies towards the development of V(NAR) single-domain proteins as viable biotherapeutics.

Proteolytic enzyme activities in Cheddar cheese juice made using lactococcal starters of differing autolytic properties.

AIMS: To determine proteolytic enzyme activities released in Cheddar cheese juice manufactured using lactococcal starter strains of differing autolytic properties. METHODS AND RESULTS: The activities of residual chymosin, cell envelope proteinase and a range of intracellular proteolytic enzymes were determined during the first 70 days of ripening when starter lactococci predominate the microbial flora. In general, in cell free extracts (CFE) of the strains, the majority of proteolytic activities was highest for Lactococcus lactis HP, intermediate for L. lactis AM2 and lowest for L. lactis 303. However, in cheese juice, as ripening progressed, released proteolytic activities were highest for the highly autolytic strain L. lactis AM2, intermediate for L. lactis 303 and lowest for L. lactis HP. CONCLUSIONS: These results indicate that strain related differences in autolysis influence proteolytic enzyme activities released into Cheddar cheese during ripening. No correlation was found between proteolytic potential of the starter strains measured in CFE prior to cheese manufacture and levels of activities released in cheese juice. SIGNIFICANCE AND IMPACT OF THE STUDY: The findings further support the importance of autolysis of lactococcal starters in determining the levels of proteolytic activities present in cheese during initial stages of ripening.

Cheddar cheese cooking temperature induces differential lactococcal cell permeabilization and autolytic responses as detected by flow cytometry: implications for intracellular enzyme accessibility.

AIMS: To determine the influence of cheese cooking temperature on autolysis and permeabilization of two lactococcal starter strains in broth and in Cheddar cheese juice during ripening. METHODS AND RESULTS: Flow cytometry (FCM) was used to identify and enumerate intact and permeabilized cells in broth and in Cheddar cheese juice. Levels of intracellular enzyme activities were quantified concurrently. Permeabilized cell numbers increased for both strains in broth following a temperature shift from 32 to 38 degrees C and was accompanied by an increase in the level of accessible intracellular enzyme activities. The relative proportions of intact and permeabilized cell populations, as detected by FCM in cheese juice, changed during 42-day ripening. Permeabilized cell populations increased during ripening for both strains; however, an increase in accessible intracellular enzyme activity was observed only for the highly autolytic strain Lactococcus lactis AM2. CONCLUSIONS: Differences in the autolytic and permeabilization response induced by cooking temperature in two lactococcal strains affects intracellular enzyme accessibility in Cheddar cheese. SIGNIFICANCE AND IMPACT OF THE STUDY: This study highlights the importance of the autolytic and permeabilization properties of lactic acid bacteria starter strains and their impact on cheese ripening.

Intranasal glomangioma.

Glomangioma is a benign tumour of the glomus body. It is a relatively rare tumour in the head and neck region and even rarer in the nasal cavity. We present the 13th documented case of an intranasal glomangioma. A 56-year-old woman presented with a lesion on the nasal septum associated with intermittent nasal pain and epistaxis. Local surgical excision was not only diagnostic but therapeutic as it effected a cure. Intranasal glomangioma has no well-defined presenting features but must be borne in mind as a possible rare cause of nasal pain and epistaxis. We also briefly review the clinical presentation, histology and management of such a rare tumour.

Contemporary breast-feeding policy and practice: implications for midwives.

In this paper, the authors draw upon recent Australian research to provide a critical commentary on the current policies and professional practices surrounding breast feeding. These studies, conducted by the first and second authors, explored aspects of the breast-feeding experience, with the findings highlighting areas for concern in relation to the promotion and support of breast feeding in western societies. Of particular concern to the authors was the number of women in these studies who equated breastfeeding with being a 'good' mother. This perception meant that some women maintained a strong commitment to breast feeding despite enormous difficulties. In this paper we firstly, overview the findings of these studies and use women's stories to illustrate their perseverance and their intense commitment to breast feeding. In the second part of the paper, we consider the consequences of the strong public rhetoric surrounding breast feeding in Australia and challenge some of the assumptions underlying policies and professional practices related to breast feeding. We examine the consequences of 'professionalising' breast feeding, and make suggestions for a way forward in the promotion of breast feeding that encompasses the range of perspectives held by women. In conclusion, the authors highlight the complexity of establishing appropriate breast-feeding policies that guide professional practices in a flexible manner, allowing for diversity in individual breast-feeding experiences.

Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care.

OBJECTIVE: To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate. DESIGN: Randomised controlled trial. SETTING: A public teaching hospital in metropolitan Sydney, Australia. Sample 1089 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital. MAIN OUTCOME MEASURES: Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity. RESULTS: There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births. CONCLUSION: Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes.

Decreased use of neonatal extracorporeal membrane oxygenation (ECMO): how new treatment modalities have affected ECMO utilization.

OBJECTIVE: Over the last decade, several new therapies, including high-frequency oscillatory ventilation (HFOV), exogenous surfactant therapy, and inhaled nitric oxide (iNO), have become available for the treatment of neonatal hypoxemic respiratory failure. The purpose of this retrospective study was to ascertain to what extent these modalities have impacted the use of neonatal extracorporeal membrane oxygenation (ECMO) at our institution. METHODS: Patients from 2 time periods were evaluated: May 1, 1993 to November 1, 1994 (group 1) and May 1, 1996 to November 1, 1997 (group 2). During the first time period (group 1), HFOV was not consistently used; beractant (Survanta) use for meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the newborn (PPHN), and pneumonia was under investigation; and iNO was not yet available. During the second time period (group 2), HFOV and beractant treatment were considered to be standard therapies, and iNO was available to patients with oxygenation index (OI) >/=25 x 2 at least 30 minutes apart, or on compassionate use basis. Patients were included in the data collection if they met the following entry criteria: 1) OI >15 x 1 within the first 72 hours of admission; 2) EGA >/=35 weeks; 3) diagnosis of MAS, PPHN or sepsis/pneumonia; 4) <5 days of age on admission; and 5) no congenital heart disease, diaphragmatic hernia, or lethal congenital anomaly. RESULTS: Of the 49 patient in group 1, 21 (42.8%) required ECMO therapy. Of these ECMO patients, 14 (66.6%) had received diagnoses of MAS or PPHN. Only 3 of the patients that went on to ECMO received beractant before the initiation of bypass (14.3%). All ECMO patients in group 1 would have met criteria for iNO had it been available. Of all patients in group 1, 18 (36.7%) were treated with HFOV, and 13 (26.5%) received beractant. Of the 47 patients in group 2, only 13 (27.7%) required ECMO therapy (compared with group 1). Of these ECMO patients, only 5 (38.5%) had diagnoses of MAS or PPHN, with the majority of patients (61.5%) requiring ECMO for sepsis/pneumonia, with significant cardiovascular compromise. Only 5 of these ECMO patients, all outborn, did not receive iNO before cannulation because of the severity of their clinical status on admission. Of all patients in group 2, 41 (87.2%) were treated with HFOV (compared with group 1), 42 (89.3%) received beractant (compared with group 1), and 18 (44.7%) received iNO. CONCLUSIONS: The results indicate that ECMO was used less frequently when HFOV, beractant and iNO was more commonly used. The differences in treatment modalities used and subsequent use of ECMO were statistically significant. We speculate that, in this patient population, the diagnostic composition of neonatal ECMO patients has changed over time.

Misplacement of dysplastic epithelium in Peutz-Jeghers Polyps: the ultimate diagnostic pitfall?

Peutz-Jeghers syndrome is characterized by multiple polyps throughout the gastrointestinal tract in association with mucocutaneous pigmentation. Small bowel polyps in the syndrome may exhibit epithelial misplacement, into the submucosa, the muscularis propria, and even the subserosa. The authors demonstrate two patients in whom there is also misplacement of dysplastic epithelium into the submucosa and muscularis propria of the small bowel. Epithelial misplacement is recognized to mimic invasive malignancy. Such mimicry is heightened substantially when the misplaced epithelium is dysplastic. Correct interpretation of the histologic changes is aided by the use of special stains, which demonstrate the associated lamina propria and the lack of a desmoplastic response, and immunohistochemistry, which shows that the misplaced dysplastic epithelium is accompanied by non-neoplastic mucosa. There is an increased prevalence of gastrointestinal malignancy in Peutz-Jeghers syndrome. However, the presence of perplexing histologic features, caused by epithelial misplacement, especially when some of that epithelium is dysplastic, in small bowel polyps at least has the potential for the overdiagnosis of malignancy in the syndrome.