Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord

Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 °C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 °C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (p = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 °C and 12 babies (9.2%) were admitted with a temperature between 36 °C and 36.4 °C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes.

Disease-severity in subsequent pregnancies with RhD immunization: a nationwide cohort

OBJECTIVE(S): to evaluate the severity of HDFN in subsequent pregnancies with RhD immunization and to identify predictive factors for severe disease. DESIGN: prospective cohort. SETTING: the Netherlands. POPULATION: nationwide selection of all pregnant women with RhD antibodies. METHODS: women with two subsequent RhD immunized pregnancies with RhD-positive children after antibodies were detected were included. MAIN OUTCOME MEASURE: the severity of HDFN in the first and subsequent pregnancy at risk. RESULTS: 62 RhD immunized women with a total of 150 RhD-positive children were included. The severity of HDFN increased significantly in the subsequent pregnancy (P<.001), although it remained equal or even decreased in 44% of women. When antibodies were already detected at first trimester screening in the first immunized pregnancy, severe HDFN in the next pregnancy was uncommon (22%), especially when no therapy or only non-intensive phototherapy was indicated during the first pregnancy (6%), or if the ADCC result remained <10%. Contrarily, women with antibodies detected during the first pregnancy of a RhD positive child (>= 27th week), most often before they had ever received RhIg prophylaxis, were most prone for severe disease in a subsequent pregnancy (48%). CONCLUSION(S): RhD-mediated HDFN in a subsequent pregnancy is generally more severe than in the first pregnancy at risk and can be estimated using moment of antibody detection and severity in the first immunized pregnancy. Women developing antibodies in their first pregnancy of a RhD-positive child are at highest risk of severe disease in the next pregnancy.

Increasing oxygen prescribing during the COVID-19 pandemic

Valid oxygen prescriptions for hospital inpatients have been a long-standing problem and have been described extensively in BMJ Open Quality with numerous quality improvement projects (QIPs) with the aim of improving compliance with oxygen prescribing.The British Thoracic Society recommends that all inpatients should have oxygen target saturation set on admission: this is motivated by risks of both undertreatment and overtreatment with oxygen. The discrepancy between the recommendation and the reality produced a number of interventions studied in QIPs over the past years, all aiming at bringing the local ward teams closer to the target. This has become even more important during the COVID-19 pandemic, where non-standard oxygen saturation targets and oxygen scarcity led hospital systems to rethink their internal guidelines on the subject.We propose three novel interventions to improve compliance: a remote, personally directed email communication to a ward pharmacist, a similar communication to ward nurses, and a remote, personally directed WhatsApp communication to junior ward doctors. We undertake a QIP which compares novel interventions developed in-house with the most successful interventions from oxygen prescribing initiatives that have previously been published by BMJ Open Quality. The main outcome measure was the proportion of patients with valid oxygen prescription on a ward.The series of novel interventions in three plan, do study, act cycles led to improvement in the outcome measure from 0% at baseline to 70% at the end of the QIP. The successful interventions from previous QIPs were ran in parallel on a similar ward and achieved improvement from 17.9% at baseline to 55.6% at the end of the QIP.This QIP demonstrates adapted interventions performed in context of social distancing aimed at members of multidisciplinary team which achieve superiority in increasing proportion of patients with a valid oxygen prescription, when compared with previously described methods from BMJ Open Quality.

Early Maxillary Dentoalveolar Changes in Children with Unilateral Cleft Lip and Palate After Palatal Repair: A Pilot Study

Objective To assess early maxillary dentoalveolar changes in children with unilateral cleft lip and palate (UCLP) up to 6 months after palatoplasty. Design Pilot study. Patients and Participants Eight children with UCLP at the age of 18 to 30 months, who were awaiting palatal repair, were included. Interventions All participants with repaired lip were scheduled for palatal repair between 18 and 24 months by Bardach's technique. Main Outcome Measure(s) Arch widths, arch depths, and arch perimeter was measured on 32 dental casts of 8 participants at 4 time points: just prior to palatal repair (T1), 1 month (T2), 3 months (T3), and 6 months (T4) after palatal repair. Manual method using digital vernier caliper (Zhart, India) was used for model analysis. Intraexaminer reliability was also assessed. Results Only one examiner assessed all the dental casts after blinding. There was a significant decrease in the intercanine width (29.75 ± 1.98 mm at T1 to 26.42 ± 1.67 mm at T4; P < .001) and anterior arch depth (9.86 ± 1.07 mm at T1 to 8.29 ± 1.51 mm at T4; P < .001). Growth occurred in intertuberosity width (38.18 ± 1.40 mm at T1 to 39.76 ± 1.09 mm at T4; P < .001) and total arch depth (24.36 ± 1.21 mm at T1 to 26.79 ± 1.04 mm; P < .001) over 6 months post-surgery. Conclusions There was growth restriction in the anterior part of the palate, whereas the posterior region continued to grow after palatal repair. These changes were observable even in the early months after palatoplasty.

Postoperative hypothermia following non-cardiac high-risk surgery: A prospective study of temporal patterns and risk factors

Background and objectives Hypothermia occurs commonly during surgery and can cause postoperative complications. We aimed to describe the characteristics and outcomes of hypothermia in patients undergoing major surgeries. Methods This prospective, observational, multicenter study of a nationally representative sample included all patients over 18 years of age admitted to an intensive care unit (ICU). Thirty ICUs were selected randomly at national level. The main outcome measure was the proportion of patients who developed postoperative hypothermia in the first 24 hours of ICU admission. Patients were divided into three groups based on temperature: <35°C, <36°C, and ≥36°C (no hypothermia). Patients’ characteristics, postoperative complications, and risk factors were evaluated in all groups. To verify whether hypothermia was a strong risk factor for postoperative complications, a Kaplan–Meier curve was generated and adjusted using a Cox regression model. Results In total, 738 patients had their temperatures measured. The percentage of patients with temperature <35°C (median [Q1-Q3], 34.7°C [34.3–34.9°C]) was 19.1% (95% confidence interval [CI] = 16.1–22.5) and that of patients with temperature <36°C (median [Q1-Q3], 35.4°C [35.0–35.8°C]) was 64% (95% CI = 58.3–70.0). The percentage of surgical complications was 38.9%. Patients with hypothermia were older, had undergone abdominal surgeries, had undergone procedures of longer duration, and had more comorbidities. A postoperative temperature ≤35°C was an independent risk for composite postoperative complications (hazard ratio = 1.523, 95% CI = 1.15–2.0), especially coagulation and infection. Conclusions Inadvertent hypothermia was frequent among patients admitted to the ICU and occurred more likely after abdominal surgery, after a long procedure, in elderly patients, and in patients with a higher number of comorbidities. Low postoperative temperature was associated with postoperative complications.

Polyester 5-0 Suture for Porous Implant Placement After Retinoblastoma Enucleation: Analysis of 120 Sockets

Background: Techniques used to suture the rectus muscle to the implant can influence the implant-related complications which is still a major problem following retinoblastoma enucleation. The goals of this work were to report the efficacy among patients with retinoblastoma who underwent enucleation followed by porous implant placement with the rectus muscles sutured with 5-0 polyester suture.Methods: This was a retrospective study of consecutive patients with retinoblastoma who underwent primary enucleation and porous implant placement with the rectus muscles tagged and sutured to the implant with polyester 5-0 suture. All the patients were followed up for a minimum of 2 years. The main outcome measure was implant exposure. The secondary efficacy measures were other implant-related complications.Results: A total of 120 patients (120 eyes) underwent primary enucleation and porous implant placement were included. Postoperatively, 10/120 (8.3%) eyes developed exposure and conjunctival granuloma. Exposure was the most common postoperative complication (7/10, 70.0%). There were no cases of implant extrusion, migration, or infection.Conclusions:Polyester 5-0 sutures are successful in patients with retinoblastoma who underwent enucleation followed by porous implant placement. Complications are minimal. Polyester 5-0 sutures were not associated with unacceptable complications in this pediatric population.

New incidence or recurrence hepatocellular carcinoma (HCC) in genotype 4 hepatitis C virus treated with sofosbuvir/daclatasvir with or without ribavirin

Background: Several studies have resulted in controversial data about the recurrence or new incidence of hepatocellular carcinoma (HCC) in patients with hepatitis C who were treated with direct-acting antivirals (DAAs). Aim: This observational study aimed to assess the occurrence rate of HCC in patients who developed a sustained virological response (SVR).. METHOD: A six-month prospective study was done at the National Hepatology and Tropical Medicine Research Institute [NHTMRI] in Cairo, Egypt on 150 chronic hepatitis C (CHC) patients treated with sofosbuvir and daclatasvir with or without ribavirin. Patients were assigned into two groups according to their laboratory values to either receive sofosbuvir/daclatasvir and ribavirin (S/D/R) or receive only sofosbuvir/daclatasvir (S/D). The main outcome measure was the occurrence of HCC. Results: SVR-12 was 100%. 8.5% of patients developed HCC in the S/D/R group, while 0% in the S/D group. Conclusion: New incidence or recurrence of HCC may occur in CHC genotype 4 cirrhotic patients receiving sofosbuvir/daclatasvir and ribavirin (difficult to treat) although achieving SVR. The cause of HCC development in this study is cirrhosis, not the administered DAAs.

Social inequalities in access to care at birth and neonatal mortality: an observational study

ObjectiveTo look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.DesignRetrospective analysis of a prospective cohort constituted using hospital discharge databases.SettingFrancePopulationLive births in 2012–2014 in maternity hospitals in mainland France followed until discharge from the hospital.Main outcome measureUnsuitability of the maternity to newborns’ needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.Results2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).ConclusionsNewborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

GnRH-Agonist Ovulation Trigger in Patients Undergoing Controlled Ovarian Hyperstimulation for IVF with Stop GnRH-Agonist Combined with Multidose GnRH-Antagonist Protocol

<b><i>Objective:</i></b> This study aimed to characterize those patients undergoing the stop gonadotropin-releasing hormone (GnRH)-agonist combined with multidose GnRH-antagonist protocol, with suboptimal response to GnRH-agonist trigger in in vitro fertilization (IVF) cycles. <b><i>Design:</i></b> This is a cohort study. <b><i>Setting:</i></b> The study was conducted in a university hospital. <b><i>Patients:</i></b> All consecutive women admitted to our IVF unit from February 2020 through November 2020 who reached the ovum pick-up stage were reviewed. <b><i>Interventions:</i></b> Triggering final oocyte maturation by GnRH-ag alone (GnRH-ag trigger group), or combined with hCG (dual trigger group), in patients undergoing the stop GnRH-agonist combined with multidose GnRH-antagonist protocol was performed. <b><i>Main Outcome Measure:</i></b> The main outcome measure was LH level 12 h after the trigger. <b><i>Results:</i></b> Five out of the 32 patients (15.6%) demonstrated suboptimal response as reflected by LH levels &#x3c;15 IU/L 12 h after GnRH-agonist trigger. Moreover, while no differences were observed in oocyte recovery rate, maturity, or embryo quality between the different study groups (GnRH-ag trigger and dual trigger groups), those achieving a suboptimal response to the GnRH-agonist trigger (post-trigger LH &#x3c;15 mIU/mL) demonstrated significantly higher number of follicles and peak estradiol levels at the day of trigger, compared to those with optimal response (post-trigger LH &#x3e;15 mIU/mL). <b><i>Conclusions:</i></b> The stop GnRH-agonist combined with GnRH-antagonist protocol enables the substitution of hCG with GnRH-ag for final oocyte maturation. However, caution should be taken in high responders, where the dual trigger with small doses of hCG (1,000–1,500 IU) should be considered, aiming to avoid suboptimal response (post-trigger LH levels &#x3c;15 IU/L).

Final Posttreatment Occlusion in Patients With Unilateral Cleft Lip and Palate

Objective: To evaluate final posttreatment occlusion in patients with complete unilateral cleft lip and palate (cUCLP) by comparing (1) 3 treatment centers, (2) males and females, (3) cleft and noncleft sides, (4) right- and left-sided clefts, and (5) orthodontic treatment with/without orthognathic surgery (OS). Design: Retrospective cohort study. Patients: Blinded posttreatment dental casts of 56 patients (19.4 ± 1.4 years) with cUCLP from 3 centers in Switzerland. Main Outcome Measure: Occlusal assessment using the modified Huddart/Bodenham (MHB) index. Results: Our sample comprised 35 males and 21 females, 46 with left- and 10 with right-sided clefts, of which 32 had undergone OS. The final posttreatment occlusion showed a median MHB score of 0 (interquartile range: −1.0 to 2.0) in the total sample and did not seem to depend on treatment center, sex, or OS. The MHB scores for the anterior buccal and the buccal segments were more negative on the cleft than on the noncleft side ( P = .002 and P = .006, respectively). When the cleft was on the left side, the MHB score tended to be more positive in the labial ( P = .046) and anterior buccal segments ( P = .034). Conclusions: This study shows a very satisfactory final posttreatment occlusion in patients with cUCLP. The more constricted buccal occlusion on the cleft side emphasizes the attention that should be given in correcting the more medially positioned lesser maxillary segment. The influence of cleft-sidedness should be analyzed further on a sample including more patients with right-sided clefts.