How is bioelectrical impedance used in neonatal intensive care? A scoping review

Poor growth and nutrition management in the neonatal period can have a negative impact upon both the short- and long-term outcomes for the infant. Improvements in bioelectrical impedance technology and accompanying licencing agreements now make this enhanced device available for use in infants as small as 23 weeks gestational age. An exploration of this technology and its use is now timely. The aim of the scoping review was to answer the following question: in preterm and sick term infants in the neonatal intensive care unit, how is bioelectrical impedance being utilized, in what situations, and when? The scoping review was conducted using Arksey and O'Malley's (Int J Soc Res Methodol 8(1):19-32, 2005) framework. Forty-nine papers were initially identified and 16 were included in the scoping review. Three studies were experimental designs, and 13 were observational studies. The review found that BIA was used in neonatal intensive care in three main ways, for, (1) fluid status evaluation, (2) as a measure of adequate nutrition and growth, (3) to validate the technology as an outcome measure in neonates.

CONCLUSION

There is a paucity of recent robust research papers which investigate the use of bioelectrical impedance in preterm neonates. Available evidence spans a range of 30 years, with technological advancement reducing the application of older studies to the modern neonatal setting. Although this technology may be helpful for decision-making around fluid management and nutrition, in preterm infants, robust evidence is needed to demonstrate the clinical benefit of bioelectrical impedance beyond that of usual care.

WHAT IS KNOWN

• Clinical decisions regarding neonatal nutrition and fluid management are currently based upon the interpretation of vital signs, fluid balance, weight trend, biochemical markers, and physical examination. • Bioelectrical Impedance Analysis (BIA) is a non-invasive method of assessing body composition which is now available to be used in infants as small as 23 weeks gestation.

WHAT IS NEW

• Bioelectrical Impedance has been used in three main ways in the NICU, for fluid status evaluation, for measuring nutrition and growth and to validate BIA as an outcome. • There is a lack of recent robust research data to support the use of the device within clinical decision making in neonatal intensive care.

Setting a direction for continuing professional development in anesthesiology: A synthesis of the outcome from an Utstein style meeting

BACKGROUND

An Utstein style meeting of key stakeholders from the existing collaboration surrounding post-graduate training was arranged to set a direction for continuing professional development (CPD) of anesthesiologists in Denmark. A 2-day meeting was planned to guide discussions about competencies in anesthesiology, facilitate the development of a blueprint for a portfolio-based CPD program and provide examples of how a portfolio can be used in practice.

METHODS

The meeting agenda was based on an adaptation of Kern's six-step approach to curriculum development. Twenty-four participants from the university hospitals in Denmark were invited. Prior to the meeting participants were informed of the objectives and the Utstein style process.

RESULTS

Participants acknowledged a need for a more structured approach to CPD, preferably within the current organizational set up at the departmental level, and with a portfolio-based, individualized curriculum. It was recognized that CPD should contain an array of possibilities to accommodate needs and wants of both the individual and the department. It was emphasized that, while anesthesiologists are used to give feedback to trainees, many are less familiar in providing the same to peers, and psychological safety was identified as a prerequisite to support a culture where specialists can reflect openly on each other's performance.

CONCLUSION

The results provide an insight into the attitudes, opportunities, and challenges of anesthesiologists in relation to continuing professional development in Denmark. Generally, participant suggestions are in line with the shift in medical education toward workplace-based learning, feedback and lifelong learning.

Parental experiences of their child's vulvovaginitis: a qualitative interview study

INTRODUCTION

Vulvovaginitis is described as a common self-limiting paediatric gynaecological condition. Parents' experiences of their child being diagnosed with this condition and subsequent treatment have not previously been described.

AIM

The aim of this study was to explore parents' experiences of their child's diagnosis and management of vulvovaginitis.

STUDY DESIGN

The study was conducted in the north west of England over a two-year period. Qualitative data were generated by semistructured in-depth interviews. Mothers of nine children with vulvovaginitis consented to participate. Data were analysed using thematic analysis.

RESULTS

The analysis of the data resulted in four themes: trauma and uncertainty of initial symptoms, seeking a diagnosis; an uncertain journey, managing the symptoms; a process of trial and error and managing the impact; keeping it private. Parents experienced a difficult and protracted journey to their child's diagnosis and were involved in a process of trial and error to try and monitor and manage what can be a difficult ongoing condition.

DISCUSSION

Clinical reports suggest that vulvovaginitis is a minor childhood condition; this is not necessarily the perceptions and experiences of parents, who can experience uncertainty and ongoing difficulty after their child's diagnosis.

CONCLUSION

The diagnosis of vulvovaginitis can have a major and ongoing impact on children's and their family's lives.

Assessing larval connectivity for marine spatial planning in the Adriatic

There are plans to start building offshore marine renewable energy devices throughout the Mediterranean and the Adriatic has been identified as a key location for wind farm developments. The development of offshore wind farms in the area would provide hard substrata for the settlement of sessile benthos. Since the seafloor of the Adriatic is predominantly sedimentary this may alter the larval connectivity of benthic populations in the region. Here, we simulated the release of larvae from benthic populations along the coasts of the Adriatic Sea using coupled bio-physical models and investigated the effect of pelagic larval duration on dispersal. Our model simulations show that currents typically carry particles from east to west across the Adriatic, whereas particles released along western coasts tend to remain there with the Puglia coast of Italy acting as a sink for larvae from benthic populations. We identify areas of high connectivity, as well as areas that are much more isolated, and discuss how these results can be used to inform marine spatial planning and the licensing of offshore marine renewable energy developments.

Parents of children with neurogenic bowel dysfunction: their experiences of using transanal irrigation with their child

BACKGROUND

Neurogenic bowel dysfunction in children is a lifelong condition often resulting in the need for active bowel management programmes, such as transanal irrigation. Parents are central in the decision-making process to initiate and carry out treatments until such a time their child becomes independent. Minimal research has focussed on examining parents' experiences of undertaking transanal irrigation with their child. This study aimed to explore parents' experiences of learning about and using irrigation with their child and how parents motivated their children to become independent.

METHODS

Semi-structured telephone interviews were conducted with parents with experience of using transanal irrigation with their child. Interviews were undertaken by a parent researcher. Data were analysed using qualitative content analysis.

RESULTS

Eighteen telephone interviews (16 mothers, 1 father and 1 carer) were conducted. Parents shared how they had negotiated getting started and using transanal irrigation with their child. They discussed a sense of success derived from their confidence in using and mastering irrigation, the process of making decisions to continue or stop using irrigation and how they motivated themselves and their child to continue with the irrigation regime. Challenges included minimizing their child's distress during the irrigation procedure and how they negotiated and moved towards their child becoming independent.

CONCLUSION

Despite the emotional difficulty parents experienced as a result of the invasive nature of transanal irrigation most parents reported an improvement in their child's faecal continence which positively impacted on the child and family's lives. The child's physical ability and emotional readiness to develop independent irrigation skills in the future concerned some parents. The experiences shared by parents in this study has the capacity to inform transanal irrigation nursing and medical care.

Parents' experiences and views of caring for a child with a tracheostomy: a literature review

OBJECTIVES

To review the published/reported experiences and views of parents' whose child has had a tracheostomy. To date, no review has focused specifically on parents' experiences and views of having a child with a tracheostomy.

METHODS

MEDLINE, CINAHL, PsycINFO and Embase were systematically searched from 1990 to 2012 and a review of reference lists was conducted. The review draws on articles where parents' views of caring for their child's tracheostomy were either the sole focus of the research or where parental views of caring for their child's tracheostomy have been sought as a subsidiary aim. Studies relating to the aims of the review were examined using quality appraisal tools and in line with criteria for inclusion of studies. Studies were excluded if findings were about adults, studies that only focused on children's or sibling's views were not based on empirical work (e.g. literature reviews or expert commentary) or were not published in the English language. Findings were summarised under thematic headings.

RESULTS

The systematic database search identified 442 citations of which 10 were eligible for inclusion in the review. Of those 10 studies six were quantitative and four qualitative. Only one paper published qualitative data specifically on parents' experiences about their tracheotomised child. The three main themes identified were parents' experiences of caregiving, their social experiences and experiences of service delivery of having a child with a tracheostomy. Although parents encountered emotional and social challenges, some positive responses to these challenges were reported.

CONCLUSION

This review identifies a lack of qualitative research on parents' views of having a child with a tracheostomy. Issues surrounding parental management of tracheostomy require further investigation. This review has identified the need to elicit parents' longitudinal experiences of having a child with a tracheostomy.

Nursing management of paediatric urethral catheterisation

This article outlines evidence-based approaches to paediatric catheterisation in acute care settings. The reasons for catheterisation, anatomy and physiology of the urinary system and the procedure and potential complications are discussed.

Sonolysis of an aqueous mixture of trichloroethylene and chlorobenzene

The effect of the initial concentration on the ultrasonic degradation of two volatile organic compounds trichloroethylene (TCE) and chlorobenzene (CB) was investigated. At higher concentrations, slower sonolysis rates were obtained due to the lowering of the average specific heat ratio gamma of the gas inside the cavitation bubbles. Furthermore, the effect of different concentrations of CB on the sonolysis of 3.34 mM TCE and the effect of different concentrations of TCE on the sonolysis of 3.44 mM CB was examined. The presence of CB lowered the sonolysis rate of TCE, while the sonolysis rate of CB did not decrease by TCE addition. An even higher sonolysis rate was obtained for 3.44 mM CB in the presence of 0.84 mM TCE than without TCE. The explanation for the different effects of both volatile organics on each other's sonolysis rate is thought to be the difference in reaction rate of TCE and CB with the radicals formed during sonolysis. The effect of TCE on the sonolysis rate of CB by lowering the gamma value is compensated by an increased indirect degradation of CB by radicals formed out of TCE. The decreased thermal degradation and the increased indirect radical degradation of CB in the presence of TCE is demonstrated by determining the kinetics of the degradation products styrene and dichlorobenzene.

Tissue pH as an indicator of mRNA preservation in human post-mortem brain

The relationship between pH and mRNA preservation in post-mortem human brain was examined using in situ hybridization histochemistry and Northern hybridization with oligonucleotide probes in a large group of human subjects, including control and neuropathological cases. Tissue pH was found to correlate strongly with preservation of four mRNA species in three brain areas. Tissue with low pH, assumed to result from prolonged terminal hypoxia, contained reduced or absent mRNA, while tissue with higher pH was found to contain quantifiable amounts, the values for pathological brain samples being comparable to those for control material of similar pH. Measurement of tissue pH provides a simple means to screen post-mortem brain for mRNA preservation and is suggested as a means to match material in case-control studies of human neurodegenerative disease.

Experience with three different third-generation cardioverter-defibrillators in patients with coronary artery disease or cardiomyopathy

Clinical investigations are being performed in multiprogrammable devices whose therapeutic options include antitachycardia pacing, cardioversion, defibrillation and bradycardia pacing. Three different third-generation devices were implanted in 46 research patients at 1 clinical center to document their safety and efficacy for the treatment of malignant ventricular arrhythmias. Additionally, the purpose of the study was to determine if antitachycardia pacing is a desirable and frequently used feature of tiered devices. The Medtronic PCD was implanted in 15 patients (12 men, mean age 60 +/- 13 years, mean ejection fraction 40 +/- 15%), the Ventritex Cadence in 21 patients (17 men, mean age 65 +/- 10 years, mean ejection fraction 38 +/- 12%), and the CPI VENTAK PRx in 10 patients (8 men, mean age 63 +/- 14 years, mean ejection fraction 31 +/- 8%). All patients presented with cardiac arrest or ventricular tachycardia. During follow-up of 10 +/- 6 months (range 1 to 19), 70% of the 20 patients with antitachycardia pacing activated used the feature for spontaneous ventricular tachycardia. The antitachycardia pacing parameters were reprogrammed 20 times in 15 patients. Two thousand six hundred thirty-eight of 2,675 (98%) antitachycardia pacing attempts successfully terminated spontaneous tachyarrhythmias. Low-energy cardioversion or defibrillation terminated tachyarrhythmias in patients where pacing was unsuccessful. One hundred forty-eight episodes of tachycardia were successfully treated directly by shocks in 16 of 46 patients (35%). There were no deaths due to device failure. This initial single-center clinical experience suggests that the PCD, Cadence and VENTAK PRx are all safe and effective tiered therapy devices for the treatment of malignant ventricular arrhythmias. Antitachycardia pacing successfully terminated most episodes of ventricular tachycardia; in patients with this feature activated, it was used frequently but required reprogramming to achieve high levels of success.

Conversion rates of induced versus spontaneous ventricular tachycardia by a third generation cardioverter defibrillator. The VENTAK PRx Phase I Investigators

Seventy consecutive patients received the first VENTAK PRx pulse generators (Cardiac Pacemakers, Inc.) implanted in the United States. This multiprogrammable device has therapeutic options that include: (1) antitachycardia pacing; (2) low energy cardioversion; (3) defibrillation shocks; and (4) bradycardia pacing. There were 60 males and 10 females with a mean age of 65.3 +/- 9.4 years. The anatomical diagnoses were coronary artery disease in 55 patients, cardiomyopathy in 7 patients, congenital heart disease in 2 patients, and miscellaneous disease in the remaining 6 patients. Thirty-six percent had a history of sudden cardiac death and 90% had documented monomorphic ventricular tachycardia. The mean ejection fraction was 32.7% +/- 12.2%. Thirty-three (49.3%) had an ejection fraction < or = 30%. Electrophysiological testing was done preimplant, predischarge, and 1 to 2 months postimplant to define a specific electrical therapy and evaluate the efficacy of the device. Two hundred ninety-three of 367 (80%) episodes of induced ventricular tachycardia were successfully terminated by the VENTAK PRx programmed for antitachycardia pacing. There were 1,794 total therapy episodes for spontaneous ventricular tachycardia; 91% (1,641 episodes) were terminated by antitachycardia pacing and 153 episodes were converted by shocks during a minimal 6-month follow-up per patient. We conclude that documentation of a successful antitachycardia pacing modality in the electrophysiology laboratory predicts conversion of spontaneous episodes of ventricular tachycardia. Furthermore, antitachycardia pacing by the VENTAK PRx can terminate the majority of episodes of ventricular tachycardia.

Ninety-six episodes of spontaneous ventricular tachycardia in 1 week: success of ramp pacing by a pacer-cardioverter-defibrillator

This case report describes the flexibility and usefulness of a pacer-cardioverter-defibrillator for the management of a 63-year-old patient with malignant ventricular tachyarrhythmias. Ninety of 96 episodes of ventricular tachycardia were terminated successfully with ramp pacing in a 1-week period. In those patients who have frequent episodes of ventricular tachycardia that respond to antitachycardia pacing, the multifunction device can add to the patient's comfort and increase acceptance of this type of device.

Effects of the angiotensin I converting enzyme inhibitor perindopril on cerebral blood flow in awake hypertensive rats

As chronic hypertension shifts the lower limit of cerebral blood flow (CBF) autoregulation to higher pressure levels, we studied the effects of the angiotensin converting enzyme (ACE) inhibitor, perindopril on mean arterial pressure (mean BP), basal CBF, and CBF autoregulation in awake renovascular hypertensive (2 kidneys, 1 clip model) and spontaneously hypertensive rats (SHR). Blood pressure was measured via a chronically implanted arterial cannula and CBF by hydrogen clearance. Chronic renovascular hypertension, like spontaneous hypertension, caused a marked shift in the lower limit of CBF autoregulation but did not alter basal CBF. In SHR, acute administration of perindopril did not diminish CBF in spite of the fact that BP fell to a level below the lower limit of CBF autoregulation (determined by hypotensive hemorrhage). Chronic treatment of renovascular hypertensive rats with perindopril normalized BP and restored CBF autoregulation.

A prospective study utilizing a transtelephonic electrocardiographic transmission program to manage patients in the first several months post-ICD implant

We prospectively enrolled 20 consecutive patients (11 men and 9 women; mean age 63 +/- 9.5 years) post-AICD implant in a transtelephonic electrocardiographic transmission (TET) program. The monitor was chosen for its retrograde (30 seconds) and antegrade memory capabilities (45 seconds). The patients were discharged from the hospital after receiving instructions to utilize the system for any cardiac symptoms. The monitor was worn 1-3 months (mean 2.5 +/- 0.7 months). During the follow-up period there were 54 TETs received. Nine were for documented AICD discharges, 19 were for symptoms associated with arrhythmias (11 of these 19 reported AICD discharges that were not documented), and 26 for symptoms not associated with arrhythmias. Eight of the 9 AICD discharges documented were appropriate for ventricular tachycardia (mean 185 +/- 40 beats/min). The arrhythmias associated with symptoms were: atrial fibrillation (12); nonsustained ventricular tachycardia (3); ventricular couplets (2); ventricular premature beats (10); and atrial premature contractions (2). Several TETs documented multiple arrhythmias. The most common symptoms not associated with arrhythmias were shortness of breath, dizziness, chest pain, and nervousness. Office interrogation of the AICDs revealed 12 of the 20 patients (60%) had received AICD discharges, with 5 of these 12 patients unaware of this occurring. We found the TET monitoring system a useful tool in the management of the AICD patient the first several months postoperatively. We were able to assess device function and avoid unnecessary office visits and/or hospitalizations.

Long-term community hospital experience with the internal defibrillator

Seventy-seven patients with drug refractory ventricular tachycardia (57) and ventricular fibrillation (20) received the implantable defibrillator. There were 55 men and 22 women with a mean age of 63 +/- 10 years. The anatomical diagnoses were coronary artery disease in 61 patients, cardiomyopathy in 15 patients, and aortic stenosis in one patient. The mean ejection fraction was 32 +/- 12%. Concurrent surgery at defibrillator implantation was coronary bypass in eight patients and aortic valve replacement in one patient. There were no intraoperative mortalities. The mean ventricular fibrillation termination threshold was 13 +/- 6 joules. During a follow-up period of 16 +/- 10 months (range 2-40 months) four patients died: electrical mechanical dissociation (two patients), respiratory failure, and sepsis. Thirty-eight patients (51%) continued receiving antiarrhythmic drug therapy, with quinidine sulfate and procainamide being the most frequently utilized agents. Fifty-four patients (72%) have received a mean of 9 +/- 10 shocks (range 1-44). Implantable defibrillators are often needed in patients seen in large community hospitals. This technology can be administered successfully in this setting with complications and results comparable to those reported from university hospitals. Implantable defibrillators are effective in preventing arrhythmic death and can be used with low risk to the patients.

Chronic treatment with the angiotensin I converting enzyme inhibitor, perindopril, restores the lower limit of autoregulation of cerebral blood flow in the awake renovascular hypertensive rat

Chronic hypertension shifts the lower limit of cerebral blood flow autoregulation to a higher pressure level. Although acute administration of angiotensin converting enzyme inhibitors restores the lower limit of cerebral blood flow autoregulation the chronic effects have not received much attention. We studied the effect of the angiotensin converting enzyme inhibitor, perindopril, on mean arterial pressure, basal cerebral blood flow and cerebral blood flow autoregulation in renovascular hypertensive (two-kidney, one clip model) and normotensive male Wistar rats. Seven weeks after renal artery clipping or sham operation rats received daily intraperitoneal injections of perindopril. The dose was increased from 1 to 8 mg/kg over the first 4 weeks until blood pressure was normalized. Chronic renovascular hypertension caused a marked shift in the lower limit of cerebral blood flow autoregulation but did not alter basal cerebral blood flow. Treatment of hypertensive rats with perindopril normalized blood pressure and restored cerebral blood flow autoregulation. Chronic treatment of normotensive rats with perindopril increased basal cerebral blood flow. In conclusion, chronic treatment of renovascular hypertensive rats with perindopril causes a shift in the lower limit of cerebral blood flow autoregulation towards the value observed in normotensive rats.