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Abstract
Health policy and quality improvement initiatives exist symbiotically. Quality projects can be spurred by policy decisions, such as the creation of financial incentives for high-value care. Then, advocacy can streamline high-value care, offering opportunities for quality improvement scholars to create projects consistent with evidenced-based care. Thirdly, as pediatrics and neonatology reconcile with value-based payment structures, successful quality initiatives may serve as demonstration projects, illustrating to policy-makers how best to allocate and incentivize resources that optimize newborn health. And finally, quality improvement (QI) can provide an essential link between broad reaching advocacy principles and boots-on-the-ground local or regional efforts to implement good ideas in ways that work practically in particular environments. In this paper, we provide examples of how national legislation elevated the importance of QI, by penalizing hospitals for low quality care. Using Medicaid coverage of pasteurized human donor milk as an example, we discuss how advocacy improved cost-effectiveness of treatments used as tools for quality projects related to reduction of necrotizing enterocolitis and improved growth. We discuss how the future of QI work will assist in informing the agenda as neonatology transitions to value-based care. Finally, we consider how important local and regional QI work is in bringing good ideas to the bedside and the community.
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Affiliation(s)
- Shetal Shah
- Division of Neonatology, Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY, USA, 100 Woods Road, C-2225A, Valhalla, NY 10595, USA.
| | - Lily Lou
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Illinois School of Medicine, 840 S. Wood Street (M/C 856), Suite 1252, Chicago, IL 60612, USA
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2
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Fiesack S, Smits A, Rayyan M, Allegaert K, Alliet P, Arts W, Bael A, Cornette L, De Guchtenaere A, De Mulder N, George I, Henrion E, Keiren K, Kreins N, Raes M, Philippet P, Van Overmeire B, Van Winckel M, Vlieghe V, Vandenplas Y. Belgian Consensus Recommendations to Prevent Vitamin K Deficiency Bleeding in the Term and Preterm Infant. Nutrients 2021; 13:nu13114109. [PMID: 34836364 PMCID: PMC8621883 DOI: 10.3390/nu13114109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal vitamin K prophylaxis is essential to prevent vitamin K deficiency bleeding (VKDB) with a clear benefit compared to placebo. Various routes (intramuscular (IM), oral, intravenous (IV)) and dosing regimens were explored. A literature review was conducted to compare vitamin K regimens on VKDB incidence. Simultaneously, information on practices was collected from Belgian pediatric and neonatal departments. Based on the review and these practices, a consensus was developed and voted on by all co-authors and heads of pediatric departments. Today, practices vary. In line with literature, the advised prophylactic regimen is 1 or 2 mg IM vitamin K once at birth. In the case of parental refusal, healthcare providers should inform parents of the slightly inferior alternative (2 mg oral vitamin K at birth, followed by 1 or 2 mg oral weekly for 3 months when breastfed). We recommend 1 mg IM in preterm <32 weeks, and the same alternative in the case of parental refusal. When IM is perceived impossible in preterm <32 weeks, 0.5 mg IV once is recommended, with a single additional IM 1 mg dose when IV lipids are discontinued. This recommendation is a step towards harmonizing vitamin K prophylaxis in all newborns.
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Affiliation(s)
- Simon Fiesack
- Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium; (S.F.); (K.K.)
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (A.S.); (M.R.); (K.A.)
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Maissa Rayyan
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (A.S.); (M.R.); (K.A.)
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (A.S.); (M.R.); (K.A.)
- Department of Pharmacy and Pharmaceutical Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC, 3011 Rotterdam, The Netherlands
| | - Philippe Alliet
- Department of Paediatrics, Jessa Hospital, 3500 Hasselt, Belgium; (P.A.); (M.R.)
| | - Wim Arts
- Department of Paediatrics, ZOL Genk, 3600 Genk, Belgium;
| | - An Bael
- Department of Pediatrics, ZNA Queen Paola Children’s Hospital, Faculty of Medicine UA, 2020 Antwerp, Belgium;
| | - Luc Cornette
- Department of Neonatology, AZ Sint-Jan, 8000 Brugge, Belgium;
| | | | - Nele De Mulder
- Vrije Universiteit Brussel (VUB), UZ Bussel, KidZ Health Castle, 1090 Brussels, Belgium;
| | | | - Elisabeth Henrion
- Department of Neonatal Intensive Care, CHR Sambre et Meuse, 5000 Namur, Belgium;
| | - Kirsten Keiren
- Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium; (S.F.); (K.K.)
| | - Nathalie Kreins
- Neonatal Intensive Care Unit, CHC MontLégia, 4000 Liège, Belgium;
| | - Marc Raes
- Department of Paediatrics, Jessa Hospital, 3500 Hasselt, Belgium; (P.A.); (M.R.)
| | | | | | - Myriam Van Winckel
- Department of Paediatrics, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Vinciane Vlieghe
- Neonatal Intensive Care Unit, Queen Fabiola Children’s University Hospital, Université Libre de Bruxelles, 1020 Bruxelles, Belgium;
| | - Yvan Vandenplas
- Department of Pediatrics, ZNA Queen Paola Children’s Hospital, Faculty of Medicine UA, 2020 Antwerp, Belgium;
- Vrije Universiteit Brussel (VUB), UZ Bussel, KidZ Health Castle, 1090 Brussels, Belgium;
- Correspondence: ; Tel.: +32-475748794
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Chawla D, Chirla D, Dalwai S, Deorari AK, Ganatra A, Gandhi A, Kabra NS, Kumar P, Mittal P, Parekh BJ, Sankar MJ, Singhal T, Sivanandan S, Tank P. Perinatal-Neonatal Management of COVID-19 Infection - Guidelines of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP). Indian Pediatr 2020; 57:536-548. [PMID: 32238615 PMCID: PMC7340735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/12/2023]
Abstract
JUSTIFICATION During the current rapidly evolving pandemic of COVID-19 infection, pregnant women with suspected or confirmed COVID-19 and their newborn infants form a special vulnerable group that needs immediate attention. Unlike other elective medical and surgical problems for which care can be deferred during the pandemic, pregnancies and childbirths continue. Perinatal period poses unique challenges and care of the mother-baby dyads requires special resources for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period. PROCESS The GRADE approach recommended by the World Health Organization was used to develop the guideline. A Guideline Development Group (GDG) comprising of obstetricians, neonatologists and pediatricians was constituted. The GDG drafted a list of questions which are likely to be faced by clinicians involved in obstetric and neonatal care. An e-survey was carried out amongst a wider group of clinicians to invite more questions and prioritize. Literature search was carried out in PubMed and websites of relevant international and national professional organizations. Existing guidelines, systematic reviews, clinical trials, narrative reviews and other descriptive reports were reviewed. For the practice questions, the evidence was extracted into evidence profiles. The context, resources required, values and preferences were considered for developing the recommendations. OBJECTIVES To provide recommendations for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period. RECOMMENDATIONS A set of twenty recommendations are provided under the following broad headings: 1) pregnant women with travel history, clinical suspicion or confirmed COVID-19 infection; 2) neonatal care; 3) prevention and infection control; 4) diagnosis; 5) general questions.
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Affiliation(s)
| | - Dinesh Chirla
- Intensive Care Services, Rainbow Children's hospital group, Mumbai, India
| | - Samir Dalwai
- Department of Pediatrics, Nanavati and Hinduja Hospitals, Mumbai, India
| | | | | | - Alpesh Gandhi
- Department of Obstetrics and Gynecology, Arihant Women's hospital, Ahmedabad, India
| | | | - Praveen Kumar
- Department of Pediatrics, PGIMER, Chandigarh, India. Correspondence to: Dr Praveen Kumar, Professor, Department of Pediatrics, PGIMER, Chandigarh, India.
| | - Pratima Mittal
- Department of Obstetrics and Gynecology, VMMC and SJH, New Delhi, India
| | | | | | - Tanu Singhal
- Department of Pediatrics and Infectious Diseases, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute (KDAHMRI), Mumbai, India
| | | | - Parikshit Tank
- Department of Obstetrics and Gynecology, Ashwini Maternity and Surgical Centre, Mumbai; India
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Marsinyach Ros I, Sanchez García L, Sanchez Torres A, Mosqueda Peña R, Pérez Grande MDC, Rodríguez Castaño MJ, Elorza Fernández MD, Sánchez Luna M. Evaluation of specific quality metrics to assess the performance of a specialised newborn transport programme. Eur J Pediatr 2020; 179:919-928. [PMID: 31993775 PMCID: PMC7223594 DOI: 10.1007/s00431-020-03573-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 12/20/2019] [Accepted: 01/10/2020] [Indexed: 12/02/2022]
Abstract
There is a lack of consensus on quality indicators suitable for neonatal transport. The aim of this study is to make a proposal for specific quality indicators for newborn transport. A retrospective descriptive study was performed (2009 to 2015) where twenty-four indicators were selected, evaluated and classified according to the 6 dimensions of quality of the Institute of Medicine. Among the 24 evaluated quality metrics, there were 3 of them which needed a correction when evaluating neonatal transport performance, because they were significantly correlated with gestational age. They were (a) stabilisation time, (b) prevalence of newborn arterial hypotension (defined by gestational age) and (c) unnoticed hypothermia at referral hospital.Conclusion: Quality evaluation through the definition of specific metrics in newborn transport is feasible. These indicators should be defined or adjusted for newborn population to measure the actual performance of the transport service.What is Known:• Quality indicators may help in defining metrics for clinical practice, promoting benchmarking and defining areas of improvement.• Newborn characteristics call for a specialised care, and quality measure during newborn transport require specific metrics. Quality metrics for paediatric transport have been defined using Delphi method. Some of these measures need to be specific for newborn, due to their intrinsic characteristics.What is New:• Using evidence-based literature and our newborn transport experience, specific quality indicators for newborn transport are suggested.• Data analysis shows how some indicators need to be adjusted for gestational age.
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Affiliation(s)
- Itziar Marsinyach Ros
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Gregorio Marañón Hospital, O’Donnell 48 Street, 28009 Madrid, Spain
| | - Laura Sanchez García
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Ana Sanchez Torres
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Rocio Mosqueda Peña
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria del Carmen Pérez Grande
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria José Rodríguez Castaño
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Manuel Sánchez Luna
- Newborn Specialized Transport Madrid (SUMMA 112), Neonatology Department, Gregorio Marañón Hospital, O’Donnell 48 Street, 28009 Madrid, Spain
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Abstract
OBJECTIVE To describe some characteristics of the 97 teaching hospitals participating in the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON-Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology). METHODS The semester prior to the beginning of the program was adopted as the baseline to evaluate the subsequent structural and processes changes of this project. Secondary data from the first half of 2017 were extracted from the National Registry of Health Establishments (NRHE), the Hospital Information System and the Sistema de Informações sobre Nascidos Vivos (SINASC-Live Birth Information System). RESULTS Before the implementation of the project, only 66% of the hospitals had a Baby-friendly Hospital Initiative, only 3% offered special accommodations for high-risk pregnant women, mothers and their newborns, and 45.4% hospitals adopted the skin-to-skin contact; 97% hospitals had separate rooms for pre-labor and vaginal delivery (93%), not following the recommendations of the Ministry of Health; nine hospitals (9%) had no rooming-in; there were few obstetrics nurses (less than 1% of professionals enrolled in the NRHE), and in only six hospitals the proportion of births assisted by this professional was above 50% of vaginal deliveries, while in eight this percentage ranged between 15% and 50%; the average cesarean section rate was 42%, ranging between 37.6% (Southeast) and 49.1% (Northeast); ten hospitals did not charge for companions according to inpatient hospital authorization. CONCLUSION The study strengthens the relevance of the Apice ON project as an inducer of change of the care model in teaching hospitals and, therefore, as a strategy for the implementation of the national public policy represented by the Stork Network.
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Affiliation(s)
- Yluska Myrna Meneses Brandão e Mendes
- Universidade de BrasíliaFaculdade de Ciências da SaúdeDepartamento de Saúde ColetivaBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ciências da Saúde. Departamento de Saúde Coletiva. Brasília/DF, Brasil
- Ministério da SaúdeSecretaria de VigilânciaBrasíliaDFBrasilMinistério da Saúde. Secretaria de Vigilância. Brasília/DF, Brasil
| | - Daphne Rattner
- Universidade de BrasíliaFaculdade de Ciências da SaúdeDepartamento de Saúde ColetivaBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ciências da Saúde. Departamento de Saúde Coletiva. Brasília/DF, Brasil
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6
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Folgori L, Lutsar I, Standing JF, Walker AS, Roilides E, Zaoutis TE, Jafri H, Giaquinto C, Turner MA, Sharland M. Standardising neonatal and paediatric antibiotic clinical trial design and conduct: the PENTA-ID network view. BMJ Open 2019; 9:e032592. [PMID: 31892658 PMCID: PMC6955510 DOI: 10.1136/bmjopen-2019-032592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Antimicrobial development for children remains challenging due to multiple barriers to conducting randomised clinical trials (CTs). There is currently considerable heterogeneity in the design and conduct of paediatric antibiotic studies, hampering comparison and meta-analytic approaches. The board of the European networks for paediatric research at the European Medicines Agency (EMA), in collaboration with the Paediatric European Network for Treatments of AIDS-Infectious Diseases network (www.penta-id.org), recently developed a Working Group on paediatric antibiotic CT design, involving academic, regulatory and industry representatives. The evidence base for any specific criteria for the design and conduct of efficacy and safety antibiotic trials for children is very limited and will evolve over time as further studies are conducted. The suggestions being put forward here are based on the adult EMA guidance, adapted for neonates and children. In particular, this document provides suggested guidance on the general principles of harmonisation between regulatory and strategic trials, including (1) standardised key inclusion/exclusion criteria and widely applicable outcome measures for specific clinical infectious syndromes (CIS) to be used in CTs on efficacy of antibiotic in children; (2) key components of safety that should be reported in paediatric antibiotic CTs; (3) standardised sample sizes for safety studies. Summarising views from a range of key stakeholders, specific criteria for the design and conduct of efficacy and safety antibiotic trials in specific CIS for children have been suggested. The recommended criteria are intended to be applicable to both regulatory and clinical investigator-led strategic trials and could be the basis for harmonisation in the design and conduct of CTs on antibiotics in children. The next step is further discussion internationally with investigators, paediatric CTs networks and regulators.
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Affiliation(s)
- Laura Folgori
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
- Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Irja Lutsar
- Department of Microbiology, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Joseph F Standing
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - A Sarah Walker
- Nuffield Department of Clinical Medicine; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials Methodology, UCL, London, UK
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University 96 School of Health Sciences, Thessaloniki, Greece
| | - Theoklis E Zaoutis
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hasan Jafri
- AstraZeneca, 950 Wind River Ln, Gaithersburg, MD, USA
| | - Carlo Giaquinto
- Department of Woman's and Child's Health, University of Padova, Padua, Italy
| | - Mark A Turner
- Institute of Translational Medicine, Centre for Women's Health Research, Liverpool Women's Hospital, Crown Street, Liverpool, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
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Pritchard NL, Hiscock RJ, Lockie E, Permezel M, McGauren MFG, Kennedy AL, Green B, Walker SP, Lindquist AC. Identification of the optimal growth charts for use in a preterm population: An Australian state-wide retrospective cohort study. PLoS Med 2019; 16:e1002923. [PMID: 31584941 PMCID: PMC6777749 DOI: 10.1371/journal.pmed.1002923] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/09/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Preterm infants are a group at high risk of having experienced placental insufficiency. It is unclear which growth charts perform best in identifying infants at increased risk of stillbirth and other adverse perinatal outcomes. We compared 2 birthweight charts (population centiles and INTERGROWTH-21st birthweight centiles) and 3 fetal growth charts (INTERGROWTH-21st fetal growth charts, World Health Organization fetal growth charts, and Gestation Related Optimal Weight [GROW] customised growth charts) to identify which chart performed best in identifying infants at increased risk of adverse perinatal outcome in a preterm population. METHODS AND FINDINGS We conducted a retrospective cohort study of all preterm infants born at 24.0 to 36.9 weeks gestation in Victoria, Australia, from 2005 to 2015 (28,968 records available for analysis). All above growth charts were applied to the population. Proportions classified as <5th centile and <10th centile by each chart were compared, as were proportions of stillborn infants considered small for gestational age (SGA, <10th centile) by each chart. We then compared the relative performance of non-overlapping SGA cohorts by each chart to our low-risk reference population (infants born appropriate size for gestational age [>10th and <90th centile] by all intrauterine charts [AGAall]) for the following perinatal outcomes: stillbirth, perinatal mortality (stillbirth or neonatal death), Apgar <4 or <7 at 5 minutes, neonatal intensive care unit admissions, suspicion of poor fetal growth leading to expedited delivery, and cesarean section. All intrauterine charts classified a greater proportion of infants as <5th or <10th centile than birthweight charts. The magnitude of the difference between birthweight and fetal charts was greater at more preterm gestations. Of the fetal charts, GROW customised charts classified the greatest number of infants as SGA (22.3%) and the greatest number of stillborn infants as SGA (57%). INTERGROWTH classified almost no additional infants as SGA that were not already considered SGA on GROW or WHO charts; however, those infants classified as SGA by INTERGROWTH had the greatest risk of both stillbirth and total perinatal mortality. GROW customised charts classified a larger proportion of infants as SGA, and these infants were still at increased risk of mortality and adverse perinatal outcomes compared to the AGAall population. Consistent with similar studies in this field, our study was limited in comparing growth charts by the degree of overlap, with many infants classified as SGA by multiple charts. We attempted to overcome this by examining and comparing sub-populations classified as SGA by only 1 growth chart. CONCLUSIONS In this study, fetal charts classified greater proportions of preterm and stillborn infants as SGA, which more accurately reflected true fetal growth restriction. Of the intrauterine charts, INTERGROWTH classified the smallest number of preterm infants as SGA, although it identified a particularly high-risk cohort, and GROW customised charts classified the greatest number at increased risk of perinatal mortality.
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Affiliation(s)
- Natasha L. Pritchard
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Richard J. Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Elizabeth Lockie
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Permezel
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Monica F. G. McGauren
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Amber L. Kennedy
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Brittany Green
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan P. Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Anthea C. Lindquist
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- * E-mail:
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Manja V, Guyatt G, Lakshminrusimha S, Jack S, Kirpalani H, Zupancic JAF, Dukhovny D, You JJ, Monteiro S. Factors influencing decision making in neonatology: inhaled nitric oxide in preterm infants. J Perinatol 2019; 39:86-94. [PMID: 30353082 PMCID: PMC6298829 DOI: 10.1038/s41372-018-0258-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We studied decision making regarding inhaled nitric oxide (iNO) in preterm infants with Pulmonary Hypertension (PH). STUDY DESIGN We asked members of the AAP-Society of Neonatal-Perinatal Medicine and Division-Chiefs to select from three management options- initiate iNO, engage parents in shared decision making or not consider iNO in an extremely preterm with PH followed by rating of factors influencing their decision. RESULTS Three hundred and four respondents (9%) completed the survey; 36.5% chose to initiate iNO, 42% to engage parents, and 21.5% did not consider iNO. Provider's prior experience, safety, and patient-centered care were rated higher by those who initiated or offered iNO; lack of effectiveness and cost considerations by participants who did not chose iNO. CONCLUSIONS Most neonatologists offer or initiate iNO therapy based on their individual experience. The minority who chose not to consider iNO placed higher value on lack of effectiveness and cost. These results demonstrate a tension between evidence and pathophysiology-based-therapy/personal experience.
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Affiliation(s)
- Veena Manja
- Departments of Surgery and Pediatrics, University of California at Davis, Sacramento, CA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Satyan Lakshminrusimha
- Departments of Surgery and Pediatrics, University of California at Davis, Sacramento, CA, USA.
- Department of Pediatrics, UC Davis Medical Center, 2516 Stockton Blvd, Sacramento, CA, USA.
| | - Susan Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Haresh Kirpalani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine,, Philadelphia, PA, USA
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - John J You
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Taylor N, Liang YF, Tinnion R. Neonatal palliative care: a practical checklist approach. BMJ Support Palliat Care 2018; 10:191-195. [PMID: 30224406 DOI: 10.1136/bmjspcare-2018-001532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/02/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Following publication of detailed national neonatal palliative care guidance, practical regional guidance, in the form of multidisciplinary 'checklists', was implemented aiming to improve the quality of neonatal palliative care. METHODS Case note audit was used to examine the quality of locally delivered neonatal palliative care before and after regional guidance implementation. RESULTS 27 patients were allocated to the 'before' cohort and 10 to the 'after' cohort. Introduction of the checklists was apparently associated with improvements in domains of pain relief and comfort care, monitoring, fluids and nutrition, completion of diagnostics, treatment ceiling decisions, resuscitation status and discussion with parents. Other support for parents was poorly adhered to. CONCLUSION Regional guidance improved some aspects of palliative care delivery though other areas remained suboptimal. Other strategies, for example, consultation with paediatric palliative care services, need to be considered to further improve the quality of palliative care delivered to babies with life-limiting illnesses.
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Affiliation(s)
- Naomi Taylor
- Department of paediatrics, James Cook University Hospital, Middlesbrough, UK
| | - Yi Fan Liang
- Department of paediatrics, James Cook University Hospital, Middlesbrough, UK
| | - Robert Tinnion
- Neonatal department, Royal Victoria Infirmary, Newcastle, UK
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Neyro V, Elie V, Thiele N, Jacqz-Aigrain E. Clinical trials in neonates: How to optimise informed consent and decision making? A European Delphi survey of parent representatives and clinicians. PLoS One 2018; 13:e0198097. [PMID: 29897934 PMCID: PMC5999079 DOI: 10.1371/journal.pone.0198097] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 05/14/2018] [Indexed: 11/27/2022] Open
Abstract
Objectives Parental consent for the participation of their neonate in neonatal research is influenced by the quality of the information delivered and the interaction between parents and investigators. Failure to provide important information may lead to difficulties in the decision making process of parents. This Delphi survey aims to establish a consensus between parent representatives of neonatal associations and healthcare professionals concerning the information deemed essential by both parties in order to improve the recruitment of neonates into clinical trials. Method This study was conducted in Europe among parent representatives and healthcare professionals. In this 3-phase study, 96 items were defined by the Scientific Committee (CS), composed of 11 clinicians (from 8 countries) and 1 parent representative of the European network of neonatal associations. Then the Committee of Experts (CE) composed of 16 clinicians were matched by country with 16 national parent representatives and evaluated these items in two rounds. The importance of each item was evaluated by each member of the CE on a scale between 1 and 9 based on their personal experience. Results Fifty eight items reached the second and final level of consensus. In contrast to clinicians, parent representatives preferred to be informed about the study by the physician in charge of their child. They also favoured additional support during the informed consent process and stated that both parents need to agree and sign. Conclusion The set of 58 items on which parents and clinicians reached consensus will be helpful to healthcare professionals seeking parental consent for the inclusion of a neonate in a clinical trial. Providing parents with information about the trial by the investigator in the presence of the patient’s neonatologist, developing closer contacts with parents and informing them of the available support by parents associations may be helpful for parents.
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Affiliation(s)
- Virginia Neyro
- Department of Paediatric Pharmacology and Pharmacogenetics, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Paris, France
- Doctoral School MTCI – Paris Descartes University, Paris, France
| | - Valéry Elie
- Department of Paediatric Pharmacology and Pharmacogenetics, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Paris, France
| | - Nicole Thiele
- European Foundation for the Care of Newborn Infants, EFCNI, Munich, Germany
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Paris, France
- INSERM Clinical Investigations Center CIC1426, Robert Debré Hospital, Paris, France
- EA08 – Paris Diderot University, Paris, France
- * E-mail:
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11
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Affiliation(s)
- Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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12
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Abstract
Point-of-care ultrasound (POC-US) is increasingly used especially in emergency and critical-care medicine. It is focused, quick and does not expose patients to ionizing radiation. It encompasses all organ systems and has well-defined indications. Lung ultrasound (LUS) represents one of the most exciting applications in the field of POC-US. It is particularly important to emphasize the role of LUS in neonatology due to the specific pathology inherent in lung immaturity as well as in the particular sensitivity of neonates to repeated radiation exposure. One of the main barriers to the more extensive use of the ultrasound technology is a lack of efficient and attractive training solutions followed by the structured quality-check assurance. In an effort to help bridge this gap, based on the most current literature, we developed creative and intuitive neonatal LUS algorithms. We hope they can serve as a clinical imaging guidelines and a valuable complement to the history and physical exam.
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Affiliation(s)
- D Kurepa
- Division of Neonatal-Perinatal Medicine, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - N Zaghloul
- Division of Neonatal-Perinatal Medicine, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - L Watkins
- Division of Pediatric Critical Care, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - J Liu
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Health Care Hospital, Beijing, China
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13
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Caffarelli C, Santamaria F, Di Mauro D, Mastrorilli C, Montella S, Bernasconi S. Advances in paediatrics in 2016: current practices and challenges in allergy, autoimmune diseases, cardiology, endocrinology, gastroenterology, infectious diseases, neonatology, nephrology, neurology, nutrition, pulmonology. Ital J Pediatr 2017; 43:80. [PMID: 28915908 PMCID: PMC5602868 DOI: 10.1186/s13052-017-0401-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 09/10/2017] [Indexed: 12/20/2022] Open
Abstract
This review reports main progresses in various pediatric issues published in Italian Journal of Pediatrics and in international journals in 2016. New insights in clinical features or complications of several disorders may be useful for our better understanding. They comprise severe asthma, changing features of lupus erythematosus from birth to adolescence, celiac disease, functional gastrointestinal disorders, Moebius syndrome, recurrent pneumonia. Risk factors for congenital heart defects, Kawasaki disease have been widely investigated. New diagnostic tools are available for ascertaining brucellosis, celiac disease and viral infections. The usefulness of aCGH as first-tier test is confirmed in patients with neurodevelopmental disorders. Novel information have been provided on the safety of milk for infants. Recent advances in the treatment of common disorders, including neonatal respiratory distress syndrome, hypo-glycemia in newborns, atopic dermatitis, constipation, cyclic vomiting syndrome, nephrotic syndrome, diabetes mellitus, regurgitation, short stature, secretions in children with cerebral palsy have been reported. Antipyretics treatment has been updated by national guidelines and studies have excluded side effects (e.g. asthma risk during acetaminophen therapy). Vaccinations are a painful event and several options are reported to prevent this pain. Adverse effects due to metabolic abnormalities are reported for second generation antipsychotic drugs.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci, 14 Parma, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Dora Di Mauro
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci, 14 Parma, Italy
| | - Carla Mastrorilli
- Clinica Pediatrica, Department of Medicine and Surgery, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci, 14 Parma, Italy
| | - Silvia Montella
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Sergio Bernasconi
- Pediatrics Honorary Member University Faculty, G D’Annunzio University of Chieti-Pescara, Chieti, Italy
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14
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Ryan MA, Ryan CA, Dempsey E, O'Connell R. Consent for routine neonatal procedures: A study of practices in Irish neonatal units. How do we compare with the gold standard BAPM guidelines? Ir Med J 2017; 110:584. [PMID: 28952674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The Irish National Consent Policy (NCP) proposes that the legal requirement for consent extends to all forms of interventions, investigations and treatment, carried out on or behalf of the Health Service Executive (HSE). This study employs a quantitative descriptive approach to investigate the practices for obtaining consent for an identified group of routine neonatal procedures in neonatal facilities throughout Ireland. The BAPM (British Association of Perinatal Medicine) guidelines were identified as 'gold standard' for the purposes of this study. The results indicated a lack of consistency between participating units pertaining to the modes of consent utilised and notable variances from 'gold standard' guidelines. Unanimity was evident for 3 procedures only (administering BCG, 6-in-1, and donor breast milk to infant). Significant findings related to EEG with video recordings, MRI/CT and gastro intestinal imaging, screening of an infant with suspected substance abuse or retinopathy of prematurity screening (ROP), administration of Vitamin K, and the carrying out of a lumbar puncture.
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Affiliation(s)
- M A Ryan
- Department of Neonatology, Cork University Maternity Hospital, Wilton, Cork
| | - C A Ryan
- Department of Neonatology, Cork University Maternity Hospital, Wilton, Cork
| | - E Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Wilton, Cork
| | - R O'Connell
- Department of Neonatology, Cork University Maternity Hospital, Wilton, Cork
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15
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Ben Hamida E, Ayadi I, Marrakchi Z, Quinton A. The script concordance test as a tool to evaluate clinical reasoning in neonatology. Tunis Med 2017; 95:326-330. [PMID: 29509212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Script concordance test aims to evaluate knowledge organization, which represents an essential component of the clinical competence. OBJECTIVE To build a script concordance test and demonstrate its relevance in the evaluation of Neonatology skills. METHODS A script concordance test including 20 vignettes and 20 items, was provided to 52 fourth year medical students and 11 family medicine interns. RESULTS Script concordance test scores obtained by experts were higher then those obtained by students and family medicine interns. The scores (out of 100) were 82.52 ± 7.35 CI95% [77.26-87.78] for the experts, 58.52 ± 9.72 CI95% [55.82-61.23] for the students, and 63.17±11.36 IC95% [55.53-70.81] (p<0.0001) for the interns. CONCLUSION Our data suggest that script concordance tests could be used to assess the acquisition of clinical reasoning among fourth year medical students in neonatolgy.
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16
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Fraser D. What Are You Doing About Creating a Culture of Quality in Your Unit? Neonatal Netw 2017; 36:67-68. [PMID: 28320492 DOI: 10.1891/0730-0832.36.2.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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17
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Marikar D. The diagnosis of death by neurological criteria in infants less than 2 months old: RCPCH guideline 2015. Arch Dis Child Educ Pract Ed 2016; 101:186. [PMID: 26961710 DOI: 10.1136/archdischild-2015-309706] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 02/08/2016] [Indexed: 11/03/2022]
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18
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Jacob H. Update on expanded newborn screening. Arch Dis Child Educ Pract Ed 2016; 101:139. [PMID: 26453242 DOI: 10.1136/archdischild-2015-309429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 09/11/2015] [Indexed: 11/04/2022]
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19
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Mayor S. Five minutes with . . . David Field, coauthor of perinatal mortality report. BMJ 2016; 353:i2790. [PMID: 27189176 DOI: 10.1136/bmj.i2790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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20
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Abstract
End-of-life decision-making is controversial. There are different views about when it is appropriate to limit life-sustaining treatment, and about what palliative options are permissible. One approach to decisions of this nature sees consensus as crucial. Decisions to limit treatment are made only if all or a majority of caregivers agree. We argue, however, that it is a mistake to require professional consensus in end-of-life decisions. In the first part of the article we explore practical, ethical, and legal factors that support agreement. We analyse subjective and objective accounts of moral reasoning: accord is neither necessary nor sufficient for decisions. We propose an alternative norm for decisions - that of 'professional dissensus'. In the final part of the article we address the role of agreement in end-of-life policy. Such guidelines can ethically be based on dissensus rather than consensus. Disagreement is not always a bad thing.
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21
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Abstract
Randomized clinical trials are the best method to assess the safety and efficacy of therapeutic interventions. However, it is not always clear how much evidence from randomized trials is required to change clinical practice. Throughout the history of neonatal medicine, some therapies were subject to excessive and unnecessary testing through replication of clinical trials. Other therapies were adopted into clinical practice with insufficient evidence. In only a few cases was the right amount of evidence accumulated to drive a change in practice. Here we present a case history for each of these three scenarios. Arising from these, we suggest principles to identify when enough evidence exists for a therapy to become standard practice.
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Affiliation(s)
- Elizabeth E Foglia
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara B DeMauro
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin Dysart
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Haresh Kirpalani
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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22
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Jürges H, Köberlein J. What explains DRG upcoding in neonatology? The roles of financial incentives and infant health. J Health Econ 2015; 43:13-26. [PMID: 26114589 DOI: 10.1016/j.jhealeco.2015.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 04/22/2015] [Accepted: 06/02/2015] [Indexed: 06/04/2023]
Abstract
We use the introduction of diagnosis related groups (DRGs) in German neonatology to study the determinants of upcoding. Since 2003, reimbursement is based inter alia on birth weight, with substantial discontinuities at eight thresholds. These discontinuities create incentives to upcode preterm infants into classes of lower birth weight. Using data from the German birth statistics 1996-2010 and German hospital data from 2006 to 2011, we show that (1) since the introduction of DRGs, hospitals have upcoded at least 12,000 preterm infants and gained additional reimbursement in excess of 100 million Euro; (2) upcoding rates are systematically higher at thresholds with larger reimbursement hikes and in hospitals that subsequently treat preterm infants, i.e. where the gains accrue; (3) upcoding is systematically linked with newborn health conditional on birth weight. Doctors and midwives respond to financial incentives by not upcoding newborns with low survival probabilities, and by upcoding infants with higher expected treatment costs.
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Affiliation(s)
- Hendrik Jürges
- Schumpeter School of Business and Economics, University of Wuppertal, Rainer-Gruenter-Str. 21 (FN), 42119 Wuppertal, Germany.
| | - Juliane Köberlein
- Schumpeter School of Business and Economics, University of Wuppertal, Rainer-Gruenter-Str. 21 (FN), 42119 Wuppertal, Germany.
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23
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Spitzer AR, Ellsbury D, Clark RH. The Pediatrix BabySteps® Data Warehouse--a unique national resource for improving outcomes for neonates. Indian J Pediatr 2015; 82:71-9. [PMID: 25319813 DOI: 10.1007/s12098-014-1585-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/09/2014] [Indexed: 11/25/2022]
Abstract
The Pediatrix Medical Group Clinical Data Warehouse represents a unique electronic data capture system for the assessment of outcomes, the management of quality improvement (CQI) initiatives, and the resolution of important research questions in the neonatal intensive care unit (NICU). This system is described in detail and the manner in which the Data Warehouse has been used to measure and improve patient outcomes through CQI projects and research is outlined. The Pediatrix Data Warehouse now contains more than 1 million patients, serving as an exceptional tool for evaluating NICU care. Examples are provided of how significant outcome improvement has been achieved and several papers are cited that have used the "Big Data" contained in the Data Warehouse for novel observations that could not be made otherwise.
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Affiliation(s)
- Alan R Spitzer
- The Center for Research, Education, and Quality Improvement, Pediatrix Medical Group, 1301 Concord Terrace, Sunrise, FL, USA,
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24
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Kett JC. Prenatal Consultation for Extremely Preterm Neonates: Ethical Pitfalls and Proposed Solutions. J Clin Ethics 2015; 26:241-249. [PMID: 26399674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In current practice, decisions regarding whether or not to resuscitate infants born at the limits of viability are generally made with expectant parents during a prenatal consultation with a neonatologist. This article reviews the current practice of prenatal consultation and describes three areas in which current practice is ethically problematic: (1) risks to competence, (2) risks to information, and (3) risks to trust. It then reviews solutions that have been suggested in the literature, and the drawbacks to each. Finally, it suggests that the model of prenatal consultation be altered in three ways: (1) that the prenatal consultation be viewed as a process over time, rather than a onetime event; (2) that decision making in the prenatal consultation be framed as a choice between nonresuscitation and a trial of neonatal intensive care, rather than a choice between "doing nothing" and "doing everything"; and (3) that the prenatal consultation process devote serious attention to both the transfer of information and the non-informational needs of families, rather than focus on the transfer of information alone.
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Affiliation(s)
- Jennifer C Kett
- Mary Bride Children's Hospital, 317 M.L.K. Jr. Way, Tacoma, Washington 98403 USA.
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25
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Jankowski J, Burcher P. Home birth of infants with congenital anomalies: a case study and ethical analysis of careproviders' obligations. J Clin Ethics 2015; 26:27-35. [PMID: 25794291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article presents the case of a mother who is planning a home birth with a midwife with the shared knowledge that the fetus would have congenital anomalies of unknown severity. We discuss the right of women to choose home birth, the caregivers' duty to the infant, and the careproviders' dilemma about how to respond to this request. The ethical duties of concerned careproviders are explored and reframed as professional obligations to the mother, infant, and their profession at large. Recommendations are offered based on this case in order to clarify the considerations surrounding not only home birth of a fetus with anticipated anomalies, but also to address the ethical obligations of caregivers who must navigate the unique tension between respecting the mother's wishes and the duty of the careproviders to deliver optimal care.
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Affiliation(s)
- Jane Jankowski
- Albany Medical College, 47 New Scotland Avenue, Mail Code 153, Albany, New York 12208 USA.
| | - Paul Burcher
- Obstetrics and Gynecology, Albany Medical College, Albany, New York 12208 USA.
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26
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Lantos JD, Feudtner C. SUPPORT and the Ethics of Study Implementation: Lessons for Comparative Effectiveness Research from the Trial of Oxygen Therapy for Premature Babies. Hastings Cent Rep 2014; 45:30-40. [PMID: 25530316 DOI: 10.1002/hast.407] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The design of SUPPORT has been widely misunderstood. This confusion has driven much of the debate about the trial - and threatens the whole enterpise of comparative effectiveness research.
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27
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Golombek S, Suttner D, Ehrlich R, Potenziano J. Target versus actual oxygenation index at initiation of inhaled nitric oxide in neonates with hypoxic respiratory failure: survey results from 128 patient cases. J Perinat Med 2014; 42:685-92. [PMID: 25205704 DOI: 10.1515/jpm-2014-0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/23/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is a well-established treatment for neonatal hypoxic respiratory failure (HRF). However, iNO therapy initiation criteria have not been standardized. This report describes a follow-up survey administered to neonatologists who had completed an Awareness, Trial, and Usage Survey. The objectives were to compare stated target oxygenation index (OI) versus actual OI at which iNO is initiated in respondents' patients and identify factors associated with iNO initiation at other levels. METHODS Neonatologists provided iNO-treated HRF patient data. Target and actual OI at initiation were determined. Patient groups were stratified by actual OI deviation from target [<4; at (±3); above: 4-10, 11-20, >20; not measured]. Reasons for above-target OI were determined. RESULTS Of 83 invited neonatologists, 26 (31%) participated, providing data for 128 patients; 85/128 patients (66%) had OI measured at initiation with neonatologist-stated mean target OI 18.8±5.8. Actual mean OI was 26.2±10.3. iNO was initiated ≤ target in 30/85 patients (35%); most [55/85 (65%)] had iNO initiated when OI was above target. Patients aged ≤1 day and those receiving a fraction of inspired oxygen (FiO2) of 1.0 for more than 1 h had highest OIs at initiation. CONCLUSIONS Among surveyed neonatologists who treat infants with HRF with pulmonary hypertension (PH), there is a disparity between stated target versus actual OI for iNO initiation, particularly among infants <1 day old and those receiving FiO2 of 1.0 for more than 1 h. In term/near-term neonates with HRF with PH, neonatologists should consider implementing treatment protocols to ensure iNO initiation at stated target OI levels.
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28
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Finan E, Sehgal A, Khuffash AE, McNamara PJ. Targeted neonatal echocardiography services: need for standardized training and quality assurance. J Ultrasound Med 2014; 33:1833-41. [PMID: 25253831 DOI: 10.7863/ultra.33.10.1833] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Targeted neonatal echocardiography refers to a focused assessment of myocardial performance and hemodynamics directed by a specific clinical question. It has become the standard of care in many parts of the world, but practice is variable, and there has been a lack of standardized training and evaluation to date. Targeted neonatal echocardiography was first introduced to Canada in 2006. The purpose of this study was to examine the characteristics of targeted neonatal echocardiography practice and training methods in Canadian neonatal intensive care units (NICUs). METHODS A total of 142 Canadian neonatologists were invited to participate in an online survey, which was conducted in September 2010. The survey consisted of questions related to the availability of targeted neonatal echocardiography, clinical indications, benefits and risks, and training methods. RESULTS The overall survey response rate was 65%. Forty-eight respondents (34%) indicated that targeted neonatal echocardiography was available in their units, and the program was introduced within the preceding 1 to 5 years. In centers where it was unavailable, lack of on-site echocardiography expertise was cited as the major barrier to implementation. The most common indications for targeted neonatal echocardiography included evaluation of a hemodynamically significant ductus arteriosus, systemic or pulmonary blood flow, and response to cardiovascular treatments. Only 27% of respondents, working in centers where targeted neonatal echocardiography existed, actually performed the studies themselves; most individuals completed 11 to 20 studies per month. Almost half of the respondents said that training was available in their institutions, but methods of training and evaluation were inconsistent. Eighty-seven percent of respondents reported no formalized process for assessment of ongoing competency after the initial training period. CONCLUSIONS Targeted neonatal echocardiography is becoming more widely available and is gaining acceptance in Canadian NICUs. Although training is provided in many institutions, the process is not well established, and formal evaluation is rarely performed. This study emphasizes the need for development of standards for formalized training, evaluation, and quality assurance.
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Affiliation(s)
- Emer Finan
- Mount Sinai Hospital, Toronto, Ontario, Canada (E.F.); Monash Medical Center, Melbourne, Victoria, Australia (A.S.); Rotunda Hospital, Dublin, Ireland (A.E.K.); Hospital for Sick Children, Toronto, Ontario, Canada (P.J.M.); and Departments of Pediatrics (E.F., P.J.M.) and Physiology (P.J.M.), University of Toronto, Toronto, Ontario, Canada
| | - Arvind Sehgal
- Mount Sinai Hospital, Toronto, Ontario, Canada (E.F.); Monash Medical Center, Melbourne, Victoria, Australia (A.S.); Rotunda Hospital, Dublin, Ireland (A.E.K.); Hospital for Sick Children, Toronto, Ontario, Canada (P.J.M.); and Departments of Pediatrics (E.F., P.J.M.) and Physiology (P.J.M.), University of Toronto, Toronto, Ontario, Canada
| | - Afif El Khuffash
- Mount Sinai Hospital, Toronto, Ontario, Canada (E.F.); Monash Medical Center, Melbourne, Victoria, Australia (A.S.); Rotunda Hospital, Dublin, Ireland (A.E.K.); Hospital for Sick Children, Toronto, Ontario, Canada (P.J.M.); and Departments of Pediatrics (E.F., P.J.M.) and Physiology (P.J.M.), University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Mount Sinai Hospital, Toronto, Ontario, Canada (E.F.); Monash Medical Center, Melbourne, Victoria, Australia (A.S.); Rotunda Hospital, Dublin, Ireland (A.E.K.); Hospital for Sick Children, Toronto, Ontario, Canada (P.J.M.); and Departments of Pediatrics (E.F., P.J.M.) and Physiology (P.J.M.), University of Toronto, Toronto, Ontario, Canada.
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29
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Seashore CJ. Giving birth to evidence-based care for newborns. Hosp Pediatr 2014; 4:203-204. [PMID: 24986987 DOI: 10.1542/hpeds.2014-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Carl J Seashore
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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30
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Tulassay Z. [Editorial comment: Pediatrics as a multidisciplinary discipline]. Orv Hetil 2013; 154:1487. [PMID: 24036016 DOI: 10.1556/oh.2013.29711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Affiliation(s)
- Zsolt Tulassay
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest Szentkirályi u. 46. 1088
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Abstract
The Office of Human Research Protections was not justified in issuing findings against the SUPPORT Institutions. Our community can learn from the evolving healthcare transformation into learning health systems by thinking about the novel ethical issues about standard of care research raised by the SUPPORT with the same spirit of quality improvement. The current regulatory framework and the concept of foreseeable research risks is insufficient to advance the debate about the ethics of randomization of standard clinical interventions. This article uses the example of the Wisconsin cystic fibrosis randomized clinical trial for newborn screening trial to explore the distinctions between risks of research and clinical care and waivers of informed consent for randomization. Collaborative exploration of these complex policy issues is needed and further deliberation, community engagement, and social science research will be critical to advance novel approaches for informed consent.
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Moczko JA. [Methods for assessing reliability and agreement of measurement]. Przegl Lek 2013; 70:875-879. [PMID: 24501815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Repeatedly in clinical and laboratory practice one undertakes a repeated measurements on the same objects examined with the same or different techniques. This usually occurs when through multiple measurements we wish to obtain a more reliable result or we compare the results obtained with two or more methods. This raises the question about the reliability of the results and their agreement . The article presents the effective methods for the quantification of these parameters for variables measured in at least interval scale. Theoretical concepts were illustrated with a specific example of clinical studies in neonatology.
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Affiliation(s)
- Jerzya A Moczko
- Katedra i Zaklad Informatyki i Statystyki Uniwersytetu Medycznego w Poznaniu.
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Prytherch H, Leshabari MT, Wiskow C, Aninanya GA, Kakoko DCV, Kagoné M, Burghardt J, Kynast-Wolf G, Marx M, Sauerborn R. The challenges of developing an instrument to assess health provider motivation at primary care level in rural Burkina Faso, Ghana and Tanzania. Glob Health Action 2012; 5:1-18. [PMID: 23043816 PMCID: PMC3464065 DOI: 10.3402/gha.v5i0.19120] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 08/30/2012] [Accepted: 08/31/2012] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The quality of health care depends on the competence and motivation of the health workers that provide it. In the West, several tools exist to measure worker motivation, and some have been applied to the health sector. However, none have been validated for use in sub-Saharan Africa. The complexity of such tools has also led to concerns about their application at primary care level. OBJECTIVE To develop a common instrument to monitor any changes in maternal and neonatal health (MNH) care provider motivation resulting from the introduction of pilot interventions in rural, primary level facilities in Ghana, Burkina Faso, and Tanzania. DESIGN Initially, a conceptual framework was developed. Based upon this, a literature review and preliminary qualitative research, an English-language instrument was developed and validated in an iterative process with experts from the three countries involved. The instrument was then piloted in Ghana. Reliability testing and exploratory factor analysis were used to produce a final, parsimonious version. RESULTS AND DISCUSSION This paper describes the actual process of developing the instrument. Consequently, the concepts and items that did not perform well psychometrically at pre-test are first presented and discussed. The final version of the instrument, which comprises 42 items for self-assessment and eight for peer-assessment, is then shown. This is followed by a presentation and discussion of the findings from first use of the instrument with MNH providers from 12 rural, primary level facilities in each of the three countries. CONCLUSIONS It is possible to undertake work of this nature at primary health care level, particularly if the instruments are kept as straightforward as possible and well introduced. However, their development requires very lengthy preparatory periods. The effort needed to adapt such instruments for use in different countries within the region of sub-Saharan Africa should not be underestimated.
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Affiliation(s)
- Helen Prytherch
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany.
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Barinov EK, Romodanovskiĭ PO, Cherkalina EN. [Professional errors in practical neonatology associated with blood transfusion]. Sud Med Ekspert 2012; 55:52-53. [PMID: 23008962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Affiliation(s)
- Alan R Spitzer
- The Center for Research, Education, and Quality MEDNAX Services/Pediatrix Medical Group/American Anesthesiology, 1301 Concord Terrace, Sunrise, FL 33323, USA.
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36
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Neonatal-perinatal medicine. Clin Privil White Pap 2012;:1-14. [PMID: 22372005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Nicolaides KH, Chitty LS. Fetal therapy: progress made and lessons learnt. Prenat Diagn 2011; 31:619-20. [PMID: 21660999 DOI: 10.1002/pd.2809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Nugent R, Golden WE, Hall W, Bronstein J, Grimes D, Lowery C. Locations and outcomes of premature births in Arkansas. J Ark Med Soc 2011; 107:258-259. [PMID: 21667683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Most (57.6%) of the extremely premature infants were born at a hospital without the availability of neonatal and MFM specialists, and 38.4% of the very premature were born at a hospital without a neonatologist. Increasing evidence indicates that delivery at a Level 3 facility results in better survival for these high risk infants. Health professionals, administrators and policy leaders could fashion new approaches to obstetrical care in Arkansas to improve neonatal outcomes.
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Dabrowska K, Gadzinowski J. [Are in-utero interventions justified?--perspective of neonatologists. Part I. Congenital diaphragmatic hernia (CDH)]. Ginekol Pol 2011; 82:371-377. [PMID: 21851037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION In-utero interventions are often perceived by parents as the only hope for their unborn child. Because it is neonatologists who have to deal with a sick newborn and sometimes unrealistic optimism of the parents after delivery we have taken on the task of reviewing the current knowledge concerning fetal surgeries from the neonatologist's perspective. In the first of three parts we have analyzed the data for in-utero interventions for CDH. OBJECTIVE Our main objective was to evaluate available data and to ascertain whether performing fetal surgeries for CDH is justified. METHODS Review of available literature on the subject of in-utero interventions in the fetuses with CDH was performed. Pubmed and Cochrane library were searched for relevant publications, in particular for randomized controlled trials. RESULTS In randomized controlled trial (RCT), the in-utero intervention did not improve the outcome. The results of uncontrolled clinical trials suggest that it may be beneficial in cases with severe lung hypoplasia. The RCT testing the efficacy of the procedure performed later in pregnancy in moderately severe cases in currently under way CONCLUSIONS In-utero interventions might improve survival in a carefully selected group of patients with CDH. However the evidence to support this claim is not strong, and until more data is available, in-utero interventions for CDH should only be performed in specialized centers as part of controlled clinical trial.
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Abstract
AIMS To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions. METHODS An anonymous questionnaire was distributed to consultants, trainees in neonatology, paediatrics, obstetrics and 4th medical students. It examined resuscitation scenarios of critically ill patients all needing immediate resuscitation. Outcomes were described including survival and potential long-term sequelae. Respondents were asked whether they would intubate, whether resuscitation was in the patients best interest, would they accept surrogate refusal to initiate resuscitation and in what order they would resuscitate. RESULTS The response rate was 74%. The majority would wish resuscitation for all except the 80-year-old. It was in the best interest of the 2-month-old and the 7-year-old to be resuscitated compared to the remaining scenarios (p value <0.05 for each comparison). Approximately one quarter who believed it was in a patient best interests to be resuscitated would nonetheless accept the family refusing resuscitation. Medical students were statistically more likely to advocate resuscitation in each category. CONCLUSION These results suggest resuscitation is not solely related to survival or long-term outcome and the best interest principle is applied differently, more so at the beginning of life.
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Affiliation(s)
- K Armstrong
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
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41
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[Best practices in perinatology. Best practices of the Neonatal Czech Society]. Ceska Gynekol 2011; 76 Suppl 1:1-72. [PMID: 22439234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Gmyrek D, Koch R, Vogtmann C, Kaiser A, Friedrich A. [Risk-adjusted assessment of neonatology wards by the new quality indicator "transfer rate of mature newborns"]. Z Evid Fortbild Qual Gesundhwes 2011; 105:133-138. [PMID: 21496782 DOI: 10.1016/j.zefq.2011.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE 1. The transfer rate of mature newborns will be presented as a new quality indicator. 2. Another objective of this study was to adjust the transfer rate of mature newborns of different hospitals according to their "risk" profile of patients by multivariate analysis. METHOD The perinatal database of 118,416 newborns of the Saxonian quality surveillance from 2001 to 2004 was analysed. Based on 17 clinical and 3 structural factors, a logistic regression model was used to develop a specific "risk" predictor for the quality indicator "transfer rate". RESULTS For care level III (basic care) a "risk" predictor for the transfer rate was developed, which consists of 15 factors. The AUC(ROC)-value of this quality indicator was 78.6%, which is sufficient. The hospital ranking based on the adjusted risk assessment was different from the hospital ranking prior to this adjustment. The average correction of ranking position was 10.4 for 43 clinics. CONCLUSION 1. The new quality indicator "transfer rate of mature newborns" can be recommended. 2. The application of the risk adjustment method proposed here allows for a more objective comparison of the quality indicator "transfer rate" among different hospitals.
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Affiliation(s)
- Dieter Gmyrek
- Arbeitsgruppe Qualitätssicherung Perinatologie/Neonatologie der Landesärztekammer Sachsen.
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Affiliation(s)
- Lisa Broussard
- University of Louisiana at Lafayette College of Nursing and Allied Health Professions, Lafayette, LA, USA.
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Vohr B, Stephens B, Tucker R. 35 years of neonatal follow-up in Rhode Island. Med Health R I 2010; 93:151-153. [PMID: 20533724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Betty Vohr
- Neonatal Follow-up Program, Women & Infants Hospital, Providence, RI 02905, USA.
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45
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Van Vleet MW. The ecology of neonatology in Rhode Island: improving care for newborns. Med Health R I 2010; 93:132-133. [PMID: 20533719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Marcia W Van Vleet
- Women & Infants Hospital, Department of Pediatrics, Providence, RI 02905, USA.
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46
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Padbury JF, VanVleet MW, Lester BM. Building for the future of Rhode Island's newborns. Med Health R I 2010; 93:134-138. [PMID: 20533720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- James F Padbury
- Women & Infants Hospital, Department of Pediatrics, Providence, RI 02901, USA.
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Abstract
The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home. The length of stay should also accommodate the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the infant, the ability and confidence of the mother to care for her infant, the adequacy of support systems at home, and access to appropriate follow-up care. Input from the mother and her obstetrician should be considered before a decision to discharge a newborn is made, and all efforts should be made to keep mothers and infants together to promote simultaneous discharge.
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Abstract
This contribution describes the regulation of end-of-life decisions in neonatology in the Netherlands. An account is given of the process of formulating rules, which includes a report by the Dutch Association for Paediatrics, two Court rulings, a report by a Consultation Group appointed by the Ministry of Health and a professional Protocol regulating deliberate ending of life in neonatology that was subsequently adopted as the regulation of this type of decision-making at the national level. The paper presents Dutch and comparative data on the attitude of the medical profession towards end-of-life decisions in neonatology and the frequency of such decisions in medical practice.
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Affiliation(s)
- Sofia Moratti
- Department of Legal Theory, University of Groningen, The Netherlands.
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49
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Romer PJM, Smink HJC, van Elburg RM. [Ethical case deliberations in the Neonatology Department]. Ned Tijdschr Geneeskd 2010; 154:A1246. [PMID: 20456773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A male newborn with generalized hypotonia and imminent respiratory insufficiency was diagnosed with a metabolic disorder with a bad prognosis. To assure patient anonymity the exact diagnosis is not mentioned. The clinicians and the parents had different opinions about whether the treatment started should be continued. When paediatricians and parents differ in opinion, medical and moral facts will play an important role in deciding what is in the best interest of the child. These ethical dilemmas cause moral stress. Paediatricians and parents both have an obligation to weigh and balance all facts, values and uncertainties. Ethical case deliberations can be a valuable addition towards medical decision-making. Working on the ward, an ethicist can guide ethical deliberations and help treatment teams in making moral judgments. A structured case deliberation with ethical sound arguments based on widely held norms and values can enable consensus to be reached about the best approach. The ethicist must safeguard this process and help the treatment team to deal with moral stress. Especially in paediatrics, ethical dilemmas and moral questions will occur frequently.
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Affiliation(s)
- Philip J M Romer
- VU Medisch Centrum, Afd. Neonatologie, Amsterdam, The Netherlands.
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Abstract
Few interventions and treatments for premature infants have undergone the rigors of a randomized controlled trial (RCT), the cornerstone of evidence-based healthcare. Multiple barriers in establishing a quality evidence base for the care of preterm infants are examined including the systematic exclusion of children from drug trials, vulnerability of the infants, burden to families of the consent process for RCTs, and the lack of standard measurements and subgroup definitions that impede systematic reviews. Delays in getting evidence into practice are highlighted, including clinician knowledge of existing evidence, attitudes about the evidence, and behavior. Landmark trials are used as examples. Finally, a call for the research community to develop guidance on good clinical research practice for preterm infants is offered that will allow the synthesis of the totality of evidence.
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Affiliation(s)
- Pamela K Donahue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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