Special Care Unit Research Articles

The Effect of Vitamin D Supplementation as Adjuvant to Phototherapy versus Phototherapy Alone on Neonatal Jaundice: A Randomised Controlled Trial

Introduction: Neonatal jaundice, or neonatal hyperbilirubinaemia, is a common and significant concern among newborns globally. Given that phototherapy is the primary treatment for neonatal jaundice, exploring alternative adjunctive treatments is beneficial. Aim: To observe the impact of vitamin D supplementation as an adjuvant therapy alongside phototherapy in managing neonatal jaundice. Materials and Methods: A hospital-based double-blinded randomised controlled trial was conducted at the Special Newborn Care Unit (SNCU) in Department of Paediatrics, G.R. Medical College, Gwalior, Madhya Pradesh, a tertiary care neonatal centre in North India, over a two-year period (April 2020 to March 2022). The study included 70 newborns with neonatal jaundice, divided into two groups: one receiving phototherapy and vitamin D (Group 1), and the other receiving phototherapy alone (Group 2). The average levels of bilirubin were compared at baseline, 48 hours, 96 hours, and 120 hours in the two groups. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) 22.0, calculating frequency, percentage, mean, Standard Deviation (SD), and applying the independent t-test for comparison. A p-value less than 0.05 was considered statistically significant. Results: The mean total serum bilirubin at admission in Group 1 was 18.58±1.76 mg/dL, and in Group 2 was 17.77±2.01 mg/ dL, with a p-value of 0.077. At 48 hours, the levels in Group 1 were 15.11±1.99 mg/dL, and in Group 2 were 14.69±1.53 mg/ dL, with a p-value of 0.339. At 96 hours, the levels in Group 1 were 14.75±5.62 mg/dL, and in Group 2 were 13.16±1.49 mg/ dL, with a p-value of 0.237. At 120 hours, the levels in Group 1 were 8.90±4.66 mg/dL, and no patients were observed in Group 2. The study found that vitamin D as an adjuvant to phototherapy did not significantly impact the rate of decline of serum bilirubin, and the duration of phototherapy was not affected significantly. Conclusion: The study concludes that vitamin D, as an adjuvant to phototherapy, does not significantly affect the rate of decline of serum bilirubin, and it does not alter the duration of phototherapy when comparing both groups.

Early Predictors of Ventilator Associated Pneumonia in Preterm Neonates Admitted in a Special Newborn Care Unit

Early Predictors of Ventilator Associated Pneumonia in Preterm Neonates Admitted in a Special Newborn Care Unit

Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists

BackgroundBecause of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations. AimWe designed a survey to compare management of different APE phenotypes according to the physicians’ medical specialty, and to compare the results with what experts would do and European guidelines. MethodsFour clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case. ResultsThe intention is to present the results at national and international conferences and publish them in a peer-reviewed journal. ConclusionsThe results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.

Forecasting of neonatal mortality trend at a special new-born care unit in Odisha, India: A time-series analysis

New born mortality is a public health problem in the state of Odisha. Newborn mortality is a dynamic process and variations in mortality are observed temporally and seasonally, and also across health facilities. Prior knowledge of mortality burden can enable health system’s readiness in terms of resources allocation and timely intervention, thereby improving the chances of survival of sick newborns admitted in the hospitals. Hence, this study aimed to examine temporal trends of newborn mortality in a Special Newborn Care Unit of Saheed Laxman Nayak Medical College and Hospital (SLNMCH) in Odisha and forecast a short-term monthly projection.The Box-Jenkins approach was used to fit a seasonal autoregressive integrated moving average (SARIMA) model to the monthly recorded mortality among the hospitalized new borns in the SNCU during 2016-2020. The best-fit model for forecasting was found based on the Akaike Information Criterion.The time-series analysis revealed a modest upward trend in newborn mortality rate among SNCU admitted newborns, with peaks in the late winter and late summer months. The seasonal ARIMA (0,1,1)(1,1,1)12 model offered the best fit for time-series data. This model predicted the monthly percentage of mortality in SNCU admitted newborns in the range of 9% to 35% with respective 95% confidence interval for two years period (2021-2022).SARIMA models are useful for monitoring newborn mortality and provide an estimate of temporal trends and seasonality. The models are helpful for predicting occurrence of mortality in the SNCU of SLNMCH and could be useful for developing early warning systems. It may help in early detection, timely treatment, and prevention of serious complications in admitted sick newborns.

Continuous Electrocardiographic Monitoring for 24 Hours Before Death in Patients with Terminal Cancer.

Purposeless physiological monitoring at the end-of-life is not recommended. However, studies on how families feel regarding the death of patients with terminal cancer without continuous electrocardiographic monitoring (CEM) are lacking. To explore the impact on the quality of care and the feelings and psychological distress experienced by families when CEM is not used during the 24 hours preceding a patient's death. In this multicenter cross-sectional, self-report questionnaires were distributed to 1087 bereaved families at Japanese specialized palliative care units in 2018. Out of 671 responses, 394 valid responses were analyzed. Families of nonmonitored patients (NM-group) accounted for 79.2%, while those with bedside electrocardiogram monitoring (MB-group) and remote nurse station monitoring (MC-group) comprised 11.9% and 8.9%, respectively. In the NM-group, 85.5% expressed satisfaction without CEM, which was more than 10% lower than other groups. While 14% in the NM-group desired patient monitoring, families who received adequate explanations about CEM had lower proportions compared to the MB-group (P = .021). Univariate analyses showed no significant differences in evaluations of the quality of care and families' psychological distress (mean scores of Overall Care Satisfaction, Care Evaluation Scale, Good Death Inventory, Brief Grief Questionnaires) across all groups. While the majority of NM-group were satisfied with their patient's care without CEM, the proportion of dissatisfied families was higher than in other groups. Although not using CEM is not a major hindrance to end-of-life care for patients with terminal cancer, providing sufficient explanations may be important for satisfactory care.

Evaluating an educational program for enhancing neonatal intensive and special care nurses’ and midwives’ competence with neonatal pain management: A quasi-experimental study

Competence in neonatal pain management is influenced by the clinician’s knowledge, attitudes, and skills. The impact of an educational program on enhancing competence among Thai neonatal nurses and midwives has never been explored. This study aims to evaluate the impact of an educational program to increase nurses’ and midwives’ competence in neonatal pain management in Thai neonatal intensive and special care units (NI/SCUs). A web-based learning package with pre-, post-, and follow-up online questionnaire was administered to 68 neonatal nurses and midwives. There was a substantial increase in the total mean scores of knowledge, attitudes, and perceived self-competence in the post- and follow-up phases compared to the pre-test phase (p < 0.001). The educational program had a significant impact on Thai NI/SCU nurse and midwife competence regarding neonatal pain management. Ongoing education is needed to sustain clinicians’ competence in this area.

Impact of dementia special care units for short-stay nursing home patients.

Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients. We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool. The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode. Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.

The Impact of State Dementia Training Requirements for Nursing Homes on Antipsychotic Medication Use

ObjectivesNursing home (NH) staff often report not having adequate dementia-specific knowledge to effectively care for these residents. Between 2011 and 2019, 9 states in the United States implemented dementia training requirements for NH staff. This study evaluated whether the state-mandated dementia training for NH staff was associated with improving resident outcomes. DesignCompared trends in antipsychotic medication before and after implementation of state training requirements to trends in states without requirements. Setting and ParticipantsNHs. MethodsData from Care Compare for NHs and LTCFocus were linked to state policy data. We excluded 14 states that had implemented training requirements before the start of the study period in 2011. We estimated difference-in-differences models that compared trends in antipsychotic medication use before and after implementation of training requirements in states that have newly implemented requirements to trends in states without requirements. We also investigated whether the impact of training was larger in states with more stringent training requirements (eg, specifying a minimum number of training hours) and in NHs with a special care unit for dementia and examined similar analyses for restraint use and falls. ResultsWe found that training requirements were associated with a 0.59–percentage point reduction (95% CI −0.91 to −0.27) in antipsychotics use. Effects were larger in NHs with a special care unit for dementia and in states that had stricter training requirements. We also found that training requirements were associated with a 0.17–percentage point reduction (95% CI −0.26 to −0.07) in restraint use measure and had no impact on falls. Conclusions and ImplicationsState requirements for NH staff dementia training were associated with a small, but significant, reduction in the use of antipsychotic medication and physical restraints.

Experiences of person-centered care for sundown syndrome among nurses and nurse aides in dementia special care units: a qualitative study

BackgroundTo explore the response and management experiences of nurses and nurse aides in dementia special care units when caring for residents with sundown syndrome based on the person-centered care model.MethodsFocus group interviews were conducted among nurses and nurse aides from four dementia special care units that have been accredited by the Ministry of Health and Welfare in Taiwan. Content analysis was used for data analysis.ResultsThe 29 nurses and nurse aides were recruited to participate in the study. Analysis of interview content revealed six themes, identifying the intra-individual, inter-individual, and organizational dimensions. The central topic was commitment. Under the umbrella of commitment, six themes including self-preparation, non-suppression, diversion, pacification, continuity of meeting, and collaboration, which had 18 subthemes, emerged as responsive care practices for person-centered care when supporting residents with sundown syndrome.ConclusionsThe findings provide responsive care practices based on person-centered care for people living with dementia who develop sundown syndrome. The study can inform practices for quality of care for dementia in long-term care institutions and contribute to the development of materials for nursing training and education.

Transferring people with dementia to severe challenging behavior specialized units, an in-depth exploration

Objectives One of the main reasons for people with dementia to move to a dementia special care unit of a nursing home is challenging behavior. This behavior is often difficult to manage, and in the Netherlands, residents are sometimes relocated to a severe challenging behavior specialized unit. However, relocation often comes with trauma and should be prevented if possible. This study aimed to investigate the patient- and context-related reasons for these relocations. Methods Qualitative multiple case study using individual (n = 15) and focus group interviews (n = 4 with n = 20 participants) were held with elderly care physicians, physician assistants, psychologists, nursing staff members, and relatives involved with people with dementia and severe challenging behavior who had been transferred to a severe challenging behavior specialized unit. Audio recordings were transcribed and analyzed with thematic analysis, including directed content analysis. Results After five cases, data-saturation occurred. The thematic analysis identified three main processes: increasing severity of challenging behavior, increasing realization that the clients’ needs cannot be met, and an increasing burden of nursing staff. The interaction between these processes, triggered mainly by a life-threatening situation, led to nursing staff reaching their limits, resulting in relocation of the client. Conclusion Our study resulted in a conceptual framework providing insight into reasons for relocation in cases of severe challenging behavior. To prevent relocation, the increasing severity of challenging behavior, increasing burden on nursing staff, and increasing realization that the clients’ needs cannot be met need attention.

Routine laboratory parameters to support decision on parenteral nutrition in palliative care.

Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN. The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time. The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0). The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

Venetoclax Combined with Hypomethylating Agents in Acute Myeloid Leukemia Patients Serious Complications Admitted to a Special Hematological Intensive Care Unit

Objective: The objective of this study was to investigate the efficacy and safety of venetoclax (VEN) in combination with demethylating agents (HMAs) among newly-diagnosed acute myeloid leukemia (AML) who have fatal comorbidities. Methods: The study conducted a retrospective analysis of 16 patients with severe complications of primary acute myeloid leukemia (AML) who were admitted to the Hematology Intensive Care Unit (H-ICU) of the First Affiliated Hospital of Soochow University between January 1, 2021 and January 31, 2023. These patients were treated with the VEN+HMAs regimen. The study analyzed the remission rate, overall survival (OS) rate, and the incidence of adverse events. Results. The study included sixteen patients diagnosed with primary unfit-AML who were admitted to H-ICU. The median age was 51 years (range: 20-83), and 9 of them were male (56.2%). The mean APACHE II score was 18.9, the mean SOFA score was 6.2. The average number of days spent in the ICU was 27.3 days. Among them, 15 patients had coexisting pulmonary infections, 5 were on noninvasive ventilators, 2 were on invasive ventilators, and 5 were receiving vasoactive drugs. Additionally, 2 patients had pulmonary hemorrhage, 2 had cerebral hemorrhage, and 4 had severe tumor lysis syndrome and received CRRT treatment. Among the patients, 13 (81.25%) had primary AML, 3 (18.75%) had MDS-transformation, 4 were classified as low-risk, 2 as intermediate-risk, and 10 as high-risk. Decitabine was used in 3 patients, azacitidine in 13 patients, VEN at a maximal dose of 100 mg in 3 patients, 200 mg in 9 patients, and 400 mg in 4 patients. The median duration of venetoclax administration was 16 days. After first course of VEN+HMAs, 12 cases (75%) achieved CR/CRi, and 3 cases (18.75%) achieved partial remission (PR), resulting in an overall response rate (ORR) of 93.75%. Among the patients with TP53 mutation (5 cases), 2 achieved CR and 2 achieved PR, with an ORR of 90%. Additionally, there were 8 cases of AML-M5, of which 6 achieved CR/CRi and 2 achieved PR, with an ORR of 100%. The ORR rate was 50% in patients with invasive ventilators and 100% in patients with CRRT. The average duration of granulopathy was 23 days. All patients experienced grade 3-4 hematological adverse events (AE), with an infection incidence of 44.4% during the period of granulopathy. Among these infections, 3 cases were caused by Acinetobacter baumannii, and 1 case was caused by Klebsiella pneumoniae. There were two cases of early mortality due to cerebral hemorrhage and septic shock respectively. With a median follow-up of 9.5 months (range: 0.5-23), the overall survival (OS) rate was 43.75%, with OS rates of 83.3% and 20% in the low- and high-risk groups, respectively. Discussion: The combination of VEN+HMAs resulted in a high therapeutic response rate among newly-diagnosed AML patients with severe complications. It was found to be safe, well-tolerated, and associated with a high remission rate using reduced dosage and dosing regimen.

Experiences of Indonesian nurses in improving preterm oral feeding readiness in special care units: A qualitative descriptive study.

Many preterm infants face feeding difficulties during the transition from enteral to oral feeding due to organ immaturity, resulting in aspiration, airway instability, and oral feeding intolerance. These challenges can increase morbidity and mortality among preterm infants. Nurses play a vital role in providing interventions to minimize negative impacts and enhance the safety of preterm oral feeding. This study aimed to explore the experiences of Indonesian nurses in improving preterm oral feeding readiness. A qualitative descriptive study was conducted involving ten nurses working in intensive care units as participants through purposive sampling. Data were collected through semi-structured, in-depth interviews conducted from January to March 2023. Thematic analysis was applied for data analysis. Four key themes developed in this study: 1) comprehensive and holistic nursing assessment, 2) challenging and complex nursing issues, 3) the need for nutritional management skills, and 4) the necessity of collaborative support. Nurses play a pivotal role in enhancing oral feeding readiness among premature infants. Their responsibilities include assessing oral feeding readiness, addressing nursing challenges, and implementing multidisciplinary stimulation involving parents. This study provides a foundational framework for developing interventions to improve preterm oral feeding readiness.

Automation of ultrasonographic optic nerve sheath diameter measurement using convolutional neural networks.

Ultrasonographic optic nerve sheath (ONS) diameter is a noninvasive intracranial pressure (ICP) surrogate. ICP is monitored invasively in specialized intensive care units. Noninvasive ICP monitoring is important in less specialized settings. However, noninvasive ICP monitoring using ONS diameter (ONSD) is limited by the need for experts to obtain and perform measurements. We aim to automate ONSD measurements using a deep convolutional neural network (CNN) with a novel masking technique. We trained a CNN to reproduce masks that mark the ONS. The edges of the mask are defined by an expert. Eight models were trained with 1000 epochs per model. The Dice-similarity-coefficient-weighted averaged outputs of the eight models yielded the final predicted mask. Eight hundred and seventy-three images were obtained from 52 transorbital cine-ultrasonography sessions, performed on 46 patients with brain injuries. Eight hundred and fourteen images from 48 scanning sessions were used for training and validation and 59 images from four sessions for testing. Bland-Altman and Pearson linear correlation analyses were used to evaluate the agreement between CNN and expert measurements. Expert ONSD measurements and CNN-derived ONSD estimates had strong agreement (r = 0.7, p < .0001). The expert mean ONSD (standard deviation) is 5.27mm (0.43) compared to CNN mean estimate of 5.46mm (0.37). Mean difference (95% confidence interval, p value) is 0.19mm (0.10-0.27mm, p = .0011), and root mean square error is 0.27mm. A CNN can learn ONSD measurement using masking without image segmentation or landmark detection.

Evaluation of Measurement Properties of Supportive Environment Assessment Scales for Dementia Special Care Units: A COSMIN Systematic Review

ObjectivesTo identify, critically appraise, compare, and summarize the measurement properties of existing instruments that assess the supportive environment of dementia special care units (DSCUs). DesignSystematic review of measurement properties consistent with Consensus-based standards for the selection of health measurement instruments (COSMIN) guidelines. Settings and ParticipantsPubMed, Embase, Web of Science, CINAHL, CNKI, Wanfang, VIP, and SinoMed were searched from inception to July 21, 2023. Studies that (1) measured the supportive environment for DSCUs using any type of assessment instrument and (2) evaluated 1 or more psychometric properties of a DSCU's supportive environment assessment instruments were included. MethodsTwo reviewers independently screened, selected, extracted data, and assessed risk of bias. ResultsFourteen studies were identified that reported the psychometric properties of 8 assessment instruments. The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) exhibited relatively better results on methodological risk of bias and quality of the psychometric properties. None of the instruments reported the evaluations on hypothesis testing, cross-cultural validity/measurement invariance, measurement error, or responsiveness. Based on the summary of 32 dimensions from 8 assessment instruments, this review established 7 functional constructs for the supportive environment for DSCUs: safety maintenance, space design, external resources, sensory stimulation, humanistic care, residual function development, and professional care. In addition, this study also initially developed a conceptual framework for the supportive environment of DSCUs. Conclusion and ImplicationsTESS-NH received the rating of “best methodological quality” and outperformed other weakly recommended scales. Further studies should pay attention to developing or revalidating scales for assessing the supportive environment of DSCUs in large multicenter samples following the COSMIN methodology. Furthermore, the conceptual framework for the DSCU supportive environment will provide a theoretical reference for facilitating their hierarchical establishment and governance within diverse long-term care facilities by state authorities.

The Activity of Special Continuity Care Units in the City of Florence During the COVID-19 Pandemic.

Objectives: Worldwide, countries adopted different strategies in primary care (PC) to cope with the COVID-19 pandemic. This study aims to describe and evaluate the functions and activity load of a specific PC organizational model called "Special Continuity Care Units" (SCCU) in Florence, Italy, and to investigate the characteristics of the COVID-19 patients assisted by the service. Methods: The retrospective cross-sectional design used daily updated reports by SCCU team members to evaluate the activity load. The retrospective cohort study analyzed data of the demographics, clinical characteristics, and process outcomes of patients assisted during the second pandemic wave. Results: The analysis shows how the service activity load changed along with the epidemiological trend. Regarding people assisted by the SCCU, the median follow-up duration of symptoms was 6days; male gender and being symptomatic were predictors of hospitalization. Conclusion: Some key characteristics can be described as indispensable in PC services facing health emergencies: model flexibility, the availability of resources, networking among services to enhance coordination and resource optimization, and close collaboration with general practitioners.

Nurses' experiences of using the Integrated Palliative care Outcome Scale with patients in specialized palliative care-A qualitative focus group study.

To explore nurses' experiences of using the Integrated Palliative care Outcome Scale (IPOS) as a communication tool in specialized palliative care. This study employed a qualitative inductive approach. The Standards for Reporting Qualitative Research were followed for reporting. Five focus groups were conducted with nurses from four specialized palliative care units, and the discussions were analysed with quality content analysis. Using IPOS for communication with the patient gave an opportunity to understand the patient's care needs and to let these care needs guide care interventions. Prerequisites in terms of relation, atmosphere, skills and flexibility were needed to establish an interactive communication. It was challenging to communicate about issues that evoked emotional reactions in the patient. There was a balancing act between the use of a structured scale and overcoming communication challenges. Nonetheless, when the two complemented each other, IPOS was a useful tool for nurses to promote person-centred care.

Postnatal corticosteroid usage in United Kingdom and Ireland neonatal units.

To perform a survey on postnatal corticosteroids usage in neonatal units in the United Kingdom and Ireland. An 18-item structured questionnaire was created asking for the level of neonatal care and corticosteroid prescribing practices. A consultant neonatologist or senor specialty training registrar/advanced neonatal nurse practitioner was contacted in every neonatal unit in the UK and Ireland between September and December 2022. The response rate to the survey was 96% (203 of 211 units). Postnatal corticosteroids were prescribed in 48% of units: 5% of special care units, 43% of local neonatal units and 100% of neonatal intensive care units. Most units (90%) prescribed dexamethasone, which was prescribed to infants born at gestational ages less than 30 weeks in all those units prescribing postnatal corticosteroids, however, eight units also reported use in infants greater than 30 weeks of gestation. Dexamethasone regimens varied with starting doses from 50 to 500 μg/kg/day. Most tertiary units (97%) prescribed repeated courses of dexamethasone. In all levels of neonatal care, postnatal corticosteroids were prescribed to ventilated infants as well as those receiving non-invasive respiratory support. There is use of postnatal corticosteroids in all levels of neonatal care and much of the practice is not evidence based.

Foodborne Botulism, Canada, 2006-20211.

During 2006-2021, Canada had 55 laboratory-confirmed outbreaks of foodborne botulism, involving 67 cases. The mean annual incidence was 0.01 case/100,000 population. Foodborne botulism in Indigenous communities accounted for 46% of all cases, which is down from 85% of all cases during 1990-2005. Among all cases, 52% were caused by botulinum neurotoxin type E, but types A (24%), B (16%), F (3%), and AB (1%) also occurred; 3% were caused by undetermined serotypes. Four outbreaks resulted from commercial products, including a 2006 international outbreak caused by carrot juice. Hospital data indicated that 78% of patients were transferred to special care units and 70% required mechanical ventilation; 7 deaths were reported. Botulinum neurotoxin type A was associated with much longer hospital stays and more time spent in special care than types B or E. Foodborne botulism often is misdiagnosed. Increased clinician awareness can improve diagnosis, which can aid epidemiologic investigations and patient treatment.

Azithromycin to Prevent Sepsis of Death in Women Planning a Vaginal Birth

ABSTRACT A high proportion of peripartum maternal deaths are caused by infection and sepsis, and this proportion continues to rise. In addition, neonatal sepsis is the third most common cause of neonatal death; the 2 conditions are connected in that maternal infection causes an increased risk of neonatal sepsis. Recent studies have shown azithromycin to be effective in reducing instances of maternal infection after an unplanned cesarean delivery, but its effectiveness for infections related to vaginal delivery has not yet been examined. This study, A-PLUS (Azithromycin Prevention in Labor Use Study), was designed to investigate the effectiveness of azithromycin in women planning a vaginal delivery. This study was conducted as a multicountry, double-blind, placebo-controlled, randomized trial over 8 sites in 7 countries. Primary outcomes included maternal sepsis or death within 6 weeks of delivery, as well as stillbirth, neonatal death, or sepsis within 4 weeks of delivery. Secondary maternal outcomes included related components, such as specific infections of chorioamnionitis, endometritis, perineal wound infection, abdominal or pelvic abscess, mastitis or breast abscess, pneumonia, or pyelonephritis, as well as therapeutic use of antibiotics, duration of hospital stay, readmission, admission to a special care unit, and unscheduled health care visits. Secondary outcomes relating to neonates included similar components, specific infection, the duration of hospital stay, readmission, admission to a special care unit, unscheduled health care visits, and safety outcomes (adverse events related to medication). Final analysis included 29,278 women, with 14,590 women (and 14,687 neonates or stillbirths) in the azithromycin group and 14,688 women (and 14,782 neonates or stillbirths) in the placebo group. Maternal sepsis or death was observed in 227 patients in the azithromycin group and 344 patients in the placebo group (adjusted relative risk, 0.67; 95% confidence interval [CI], 0.56–0.79; P &lt; 0.001). Sepsis was the case in 219 in the azithromycin group and 339 in the placebo group (relative risk, 0.65; 95% CI, 0.55–0.77), and death from sepsis was rare. For neonates, stillbirth, death, or sepsis was observed in 1540 in the azithromycin group and 1526 in the placebo group (relative risk, 1.02; 95% CI, 0.95–1.09), with sepsis accounting for 1433 and 1407 cases in the azithromycin and placebo groups, respectively. Both the outcomes of stillbirth and neonatal death were relatively uncommon. Maternal adverse effects experienced from the medication were not significantly different between groups, and the azithromycin group had noticeably reduced risk of endometritis, wound infections, and several others when compared with the placebo group. These results indicate that azithromycin is consistently effective in lowering the risk of infection and sepsis in mothers and infants during vaginal delivery. The number treated to prevent 1 case of maternal death or sepsis was 125; this is consistent with previous research in individuals undergoing cesarean delivery. Although azithromycin was effective at preventing maternal infection and sepsis, there were no significant effects on neonatal outcomes. This is consistent with most previous research; reasons for discrepancies could be inclusion of different types of infections and differences in antibiotic treatment between countries. Further research could improve the generalizability of these findings by focusing on factors that influence the effectiveness of azithromycin and that impact its clinical use.