Stillbirths and neonatal deaths are devastating events for both parents and clinicians and are global public health concerns. Careful clinical management after these deaths is required, including ...appropriate investigation and assessment to determine cause (s) to prevent future losses, and to improve bereavement care for families. An educational programme for health care professionals working in maternal and child health has been designed to address these needs according to the Perinatal Society of Australia and New Zealand Guideline for Perinatal Mortality: IMproving Perinatal mortality Review and Outcomes Via Education (IMPROVE). The programme has a major focus on stillbirth and is delivered as six interactive skills-based stations. We aimed to determine participants' pre- and post-programme knowledge of and confidence in the management of perinatal deaths, along with satisfaction with the programme. We also aimed to determine suitability for international use.
The IMPROVE programme was delivered to health professionals in maternity hospitals in all seven Australian states and territories and modified for use internationally with piloting in Vietnam, Fiji, and the Netherlands (with the assistance of the International Stillbirth Alliance, ISA). Modifications were made to programme materials in consultation with local teams and included translation for the Vietnam programme. Participants completed pre- and post-programme evaluation questionnaires on knowledge and confidence on six key components of perinatal death management as well as a satisfaction questionnaire.
Over the period May 2012 to May 2015, 30 IMPROVE workshops were conducted, including 26 with 758 participants in Australia and four with 136 participants internationally. Evaluations showed a significant improvement between pre- and post-programme knowledge and confidence in all six stations and overall, and a high degree of satisfaction in all settings.
The IMPROVE programme has been well received in Australia and in three different international settings and is now being made available through ISA. Future research is required to determine whether the immediate improvements in knowledge are sustained with less causes of death being classified as unknown, changes in clinical practice and improvement in parents' experiences with care. The suitability for this programme in low-income countries also needs to be established.
Background/Objective: Hyperglycaemia is common in very premature neonates and is associated with increased risk of intraventricular haemorrhage, necrotising enterocolitis, sepsis and death. ...Administration of insulin may risk hypoglycaemia and associated complications. To determine effects of insulin infusions in very premature infants on morbidity, mortality and long-term neurodevelopmental outcome. Methods: Retrospective audit of 97 infants delivered at <29 weeks gestation and admitted to The Canberra Hospital NICU. Data on insulin treatment, Blood Glucose Levels (BGL's) prior and during insulin therapy, episodes of significant hypoglycaemia and neurodevelopmental outcome at 12 months corrected age was collected. Results: 17 (17.5%) neonates received insulin. Episodes of hypoglycaemia were infrequent (1.3%, 95% CI 0.5-2.9). Multiple regression analysis showed that insulin treatment was not associated with an increased risk of retinopathy of prematurity (OR 3.6, 95% CI 0.4-32.3) or mortality (OR 1.2, 95% CI 0.29-5.0). No significant difference in 12 month neurodevelopmental or anthropometric outcomes was detected in infants who received insulin. Conclusion: Insulin infusions for hyperglycaemia appear to be safe with infrequent episodes of hypoglycaemia, no increased risk of morbidity or mortality and no adverse effect on long-term neurodevelopmental outcome.
Background
Preterm infants are delivered while glomerulogenesis is ongoing and may be exposed to insults, including medications that may affect renal development. Podocytes detected in the urine are ...an indicator of glomerular injury. The aims of this study were to determine whether preterm and term infants excrete podocytes in their urine and whether exposure to gentamicin and indomethacin increase podocyte excretion in their urine.
Methods
Preterm infants <33 weeks gestation had urine collected each day while receiving either gentamicin or indomethacin. Preterm and term control infants had urine collected for 3 days. The number of casts and podocytes present in the urine of infants receiving indomethacin and gentamicin were compared with preterm and term control infants.
Results
Forty-two neonates were included in the study. Podocytes were present in small numbers (< 2) in the urine of both preterm and term control neonates. The number of podocytes in the preterm group receiving indomethacin was significantly higher than in all other groups (
p
= 0.02) ,as was urinary albumin (
p
= 0.02).
Conclusions
Increased number of podocytes in preterm neonates receiving indomethacin and higher excretion of albumin suggest glomerular injury is occurring. It is unknown whether injury to glomeruli during glomerulogenesis in preterm neonates has long-term sequelae for renal development and function into adulthood.
Abstract
Background/Aims
NICE now enables patients with a DAS of > 3.1 to < 5.2 to be treated with advanced drug therapies. To ensure correct and cost-effective use of resources it is essential that ...we identify a moderate DAS that is driven by inflammatory joint disease as opposed to a differential diagnosis. A reference-based tool entitled “DAS drivers: A nursing decision-making algorithm“ was designed to support nurses in their clinical decision making around appropriate treatment for moderate disease.
Clinical trials suggest that advanced therapy provides similar benefits for people with moderate disease as well as those with severe disease. After a pragmatic review of existing evidence. NICE guidance was introduced in 2021 to include patients with a moderate RA DAS (>3.1 - < 5.2) to be eligible for advanced therapies. This is a positive step to improving access to advanced treatment options for patients and will help stem the burden of disability associated with RA.
The algorithm presented was initially developed to support nurses identify and navigate around management plans for patients with moderate RA disease and would be freely available for all of rheumatology community to use in their daily practice.
It is recognised in the BSR report ‘Specialist Nursing in Rheumatology - The State of Play’ that there is a need for succession planning and an increase in appropriately skilled rheumatology nursing workforce. The authors are experienced, longstanding members of the rheumatology workforce and thus are sharing knowledge and experience with the next generation of nurses to allow for continued quality of patient care as part of the succession planning program that rheumatology services now face. The algorithm aims to address these challenges by supporting the identification of patients with active inflammation in moderate RA therefore ensuring that appropriate patients are given access to valuable limited resources within the NHS.
Methods
Round-table discussions between three advanced rheumatology nurse leaders (the authors) with a cumulative and varied rheumatology experience of 70+ years, lead to the development of an algorithm specifically around identifying active inflammation in moderate RA. The authors drew on relevant publications and clinical experience to develop the algorithm and refine over a 12-month period. The intention of the algorithm is to make it user friendly and support standardised decision making in a clinical setting for all nurses working within rheumatology, irrespective of experience.
Results
The algorithm provides a structured approach and promotes ideas to consider when assessing and treatment patients with rheumatoid arthritis.
Conclusion
To endorse and disseminate the algorithm as an education tool and develop a publication. An audit on the use of the algorithm amongst nurses in clinical practice with a pilot audit with nurses who have attended educational events delivered by the authors.
Disclosure
B. Rhys-Dillion: Honoraria; B.R.D. has received honoraria from Galapagos. A. Kent: Honoraria; A.K. has received honoraria from Galapagos, Roche, Pfizer, Gilead, BMS, Amgen, Chugai-Pharma, Sanofi Aventis and UCB Pharma. J. Painter: Honoraria; J.P. has received honoraria from Galapagos, Pfizer, Novartis and Roche/Chugai-Pharma.
Urinary ascites in a newborn infant is unusual and most commonly results from bladder perforation following umbilical arterial catheterisation or obstructive uropathy. The following report describes ...a case of fetal bladder rupture with urinary ascites in a mother ventilated and sedated with narcotics and benzodiazepines for H1N1 influenza. This was associated with a unique biochemical profile of hyponatraemia and elevated serum urea and creatinine characteristic of urinary autodialysis in the neonate.
Indomethacin, ibuprofen, and gentamicin are commonly administered to neonates between 24 and 28 wk gestation when glomerulogenesis is still occurring. Indomethacin is known to cause renal failure in ...up to 25% of infants treated. Possible morphologic effects of these drugs are largely unknown. The purpose of this study was to determine the type of renal changes found on light (LM) and electron microscopy (EM) following administration of indomethacin, ibuprofen, and gentamicin in a neonatal rat model. Rat pups were exposed to indomethacin or ibuprofen and/or gentamicin antenatally for 5 d before birth or postnatally for 5 d from d 1 of life. Pups were killed at 14 d of age. LM examination in all indomethacin- and ibuprofen-treated pups both antenatally and postnatally showed vacuolization of the epithelial proximal tubules, interstitial edema, intratubular protein deposition but no significant glomerular changes. EM examination showed pleomorphic mitochondria and loss of microvilli in the tubules. The glomeruli showed extensive foot process effacement and irregularities of the glomerular basement membrane. EM changes were most marked in pups treated antenatally with ibuprofen, and indomethacin with gentamicin postnatally. Indomethacin, ibuprofen, and gentamicin cause significant change in glomerular and tubular structure in the neonatal rat model.
To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets.
The costs of inpatient care of children with ...severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted.
The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, CI: 61.7-65.2) in the quinine arm and US$ 66.5 (95% CI: 63.7-69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively.
Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible.
: A multidisciplinary workshop with parent/consumer involvement was held to determine a consensus in the difficult arena of perinatal care of women and babies at the borderlines of viability. ...Interactive forums produced consensus statements following an extensive consultation process. A grey zone between 230 and 256 weeks of gestation was identified and agreed upon. In this grey zone, while there was an increasing obligation to treat, it was acceptable not to initiate intensive care following appropriate counselling with parents. Important areas identified before birth, were continuing communication between the perinatal team and parents, a review of choice with continued counselling, decision support and empathy. The process must be transparent, open and honest, using the most relevant up to date outcome data in a collaborative framework.
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