Therapeutic hypothermia: from lab to NICU

The possibility of a therapeutic role for cerebral hypothermia during or after resuscitation from perinatal asphyxia has been a long-standing focus of research. However, early studies had limited and contradictory results. It is now known that severe hypoxia-ischemia may not cause immediate cell death, but may precipitate a complex biochemical cascade leading to the delayed development of neuronal loss. These phases include a latent phase after reperfusion, with initial recovery of cerebral energy metabolism but EEG suppression, followed by a secondary phase characterized by accumulation of cytotoxins, seizures, cytotoxic edema, and failure of cerebral oxidative metabolism from 6 to 15 h post insult. Although many of the secondary processes can be injurious, they appear to be primarily epiphenomena of the 'execution' phase of cell death. This conceptual framework allows a better understanding of the experimental parameters that determine effective hypothermic neuroprotection, including the timing of initiation of cooling, its duration and the depth of cooling attained. Moderate cerebral hypothermia initiated in the latent phase, between one and as late as 6 h after reperfusion, and continued for a sufficient duration in relation to the severity of the cerebral injury, has been consistently associated with potent, long-lasting neuroprotection in both adult and perinatal species. The results of the first large multicentre randomized trial of head cooling for neonatal encephalopathy and previous phase I and II studies now strongly suggest that prolonged cerebral hypothermia is both generally safe - at least in an intensive care setting - and can improve intact survival up to 18 months of age. Both long-term followup studies and further large studies of whole body cooling are in progress.     

Approaches to clinical decision-making: a qualitative study of naturopaths

The type of information used and its application in clinical practice has generated interest due to its relationship to evidence-based medicine (EBM). However, it is also acknowledged that the principles of EBM place less value on practitioners' experience and intuitive insights when making clinical decisions. Research in this area has been conducted with conventional health professionals, meanwhile complementary and alternative medicine practitioners such as naturopaths have received little attention. In response interviews were undertaken with naturopaths to explore their approach to information-seeking and application in clinical settings. Thematic analysis identified how naturopaths incorporate deductive reasoning alongside intuition and clinical experience to overcome difficulties in applying information to relevant clinical situations. This research provides an understanding of the approach taken by naturopaths to improve the relevance of available data when making clinical decisions and is of significance for health policy and health service delivery in this area.     

Approaches for end-of-life care in the field of gynecologic oncology: an exploratory study

We sought to explore the Society of Gynecologic Oncologists (SGO) members' opinions and decisions about end-of-life issues and incurable conditions. A survey was mailed to members of the SGO. Their responses were recorded on a Likert scale and entered into a database. The survey explored opinions, experiences, and decisions in managing terminally ill gynecologic oncology patients. Of 900 surveys, 327 were returned (response rate, 36%). Seventy-three percent were men, 89% were white, and 72% were of Christian denomination. Respondents believed that 97% of patients who are dying realize that they are dying but stated only 40% of these patients initiate conversations about end-of-life issues. In contrast, 92% of respondents stated that they initiate end-of-life discussions with patients. Ninety-two percent of respondents thought that the patients should be allowed to make end-of-life choices independently after the facts are given to them. However, 44% thought that it is important to influence the way information is presented, and 54% believe that the gynecologic oncologist (GO) controls the outcome of end-of-life discussions. Although the physicians' sex, race, religion, and age did not correlate with their treatment decisions, religion did correlate with less fear of death (P = 0.011) and less discomfort when talking with patients about death (P = 0.005). Fifty-four percent of respondents believed that the GO controls the outcome of end-of-life discussions, and 40% believe that their actions prolong the process of dying. Expanding our understanding of what motivates GOs to recommend continued treatment over palliation is important for preserving informed patient-motivated end-of-life decisions.     

Infant end-of-life care: the parents' perspective.

OBJECTIVE: The purpose of this study was to identify factors important to parents in their infant's end-of-life care. STUDY DESIGN: Participants were parents (n=19 families) whose infant (less than 1 year old) had died. Parents completed the Revised Grief Experience Inventory (RGEI) and a semi-structured interview regarding their infant's end-of-life care. Interviews were rated using the Post-Death Adaptation Scale (PDAS). RESULTS: Parents scored significantly lower than the normative sample on the RGEI, and PDAS scores suggested that these parents were adapting positively. Parent interviews identified the aspects of care that were important to parents: honesty, empowered decision-making, parental care, environment, faith/trust in nursing care, physicians bearing witness and support from other hospital care providers. CONCLUSIONS: Results of this study suggest that parents can effectively cope following the death of an infant and the medical staff can do much to improve the end-of-life care for infants and their families.     

Life or death decisions in the NICU.

When, if ever, should we allow an extremely premature baby to die? The paper explains how that would be answered if we are guided by three reasonable assumptions. (1) The value a person's life has is primarily the value it has for that person, rather than a value it has in itself. (2) All competent persons have a right to decide for themselves whether their lives are to be prolonged. (3) Parents have a right to treat their children as they choose, so long as they neither abuse them nor neglect them.     

Grand multiparity: a reappraisal of the risks.

An excellent maternal and perinatal outcome is reported in a group of grand multipara of low socioeconomic status. These observations on a group of patients who are traditionally considered to be high risk show that in a healthy population with access to modern medical care and hospital delivery, a favorable outcome can be achieved despite a low socioeconomic or refugee status.     

Prevention and treatment of nosocomial sepsis in the NICU.

Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. It is associated with an increase in mortality, morbidity, and prolonged length of hospital stay. Thus, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to describe simple changes in process, which when implemented, can reduce nosocomial infection rates in neonates and improve outcomes.     

PretermConnect: Leveraging mobile technology to mitigate social disadvantage in the NICU and beyond

Preterm birth (PTB) – delivery prior to 37-weeks gestation – disproportionately affects low-income and minority populations and leads to substantial infant morbidity and mortality. The time following a PTB represents an optimal window for targeted interventions that encourage mothers to prioritize their own health and that of their babies. Healthcare teams can leverage digital strategies to address maternal and infant needs in this postpartum period, both in the neonatal intensive care unit and beyond. We therefore developed PretermConnect, a mobile app designed to educate, engage, and empower women at risk for PTB. This article describes the participant-centered design approach of PretermConnect, with preliminary findings from focus groups and co-design sessions in different community settings and suggested future directions for mobile technologies in population health. Apps such as PretermConnect can mitigate social disadvantage by serving as remote monitoring tools, providing social support, preventing recurrent PTB and lowering infant mortality rates.     

Hospital-acquired infections in the NICU: epidemiology for the new millennium

Nosocomial infections are an important cause of morbidity and mortality in the preterm neonate. Extrinsic and intrinsic risk factors make the preterm neonate particularly susceptible to infection. This review focuses on two major pathogens that cause nosocomial infection, Candida and methicillin-resistant Staphylococcus aureus. The difficult diagnosis of meningitis in the neonate also is discussed.     

The value of children in African countries: insights from studies on infertility

A number of studies have explored motives for parenthood in the Western industrialized world. These studies have documented that children are mostly desired for reasons relating to happiness and personal well-being. To date, limited data pertaining to parenthood motives in African countries exist. Insight into the value of children can, however, be derived from studies on infertility, as the negative repercussions of involuntary childlessness reflect the value of children to parents and the community. According to these studies children secure conjugal ties, offer social security, assist with labour, confer social status, secure rights of property and inheritance, provide continuity through re-incarnation and maintaining the family lineage, and satisfy emotional needs. Parenthood therefore appears to have more and, arguably, deeper roots in African communities when compared to industrialized countries.     

New insights into the pathophysiology of endometriosis: from chronic inflammation to danger signal

Background.?Various theories try to explain the development and progression of endometriosis, however, no single theory can explain all aspects of this disorder. Gene expression profiling studies might reveal factors that explain variability in disease development and progression, which can serve as specific biomarkers for endometriosis and novel drug development. We have recently showed that the upregulated genes were predominantly clustered in stress and detoxification, providing a mechanistic explanation for the oxidative stress and chronic inflammatory response in endometriosis.

Objective.?This review aims: (1) to analyse the published data, with the aim of identifying pathways consistently regulated by the endometriosis genotype and (2) to summarise the findings of specific genes, which are involved in the process of oxidative stress and inflammation.

Methods.?We identified gene array and proteomics studies whose data were accessible in PubMed.

Results.?A major finding is the increased expressions of several markers including heat shock protein, S100, fibronectin, and neutrophil elastase, which might be involved in the process of Toll-like receptor (TLR)-dependent sterile inflammation. The study reviews a convergence in the main pathogenic process, where the TLR-mediated inflammation occurs possibly through the endogenous ligands.

Conclusions.?In conclusion, a circulus vitiosus of both the oxidative stress pathway and the TLR pathways is generated when the process becomes chronic (danger signal spiral).     

Infant bonding and attachment to the caregiver: insights from basic and clinical science

Early life infant-caregiver attachment is a dynamic, bidirectional process that involving both the infant and caregiver. Infant attachment appears to have a dual function. First, it ensures the infant remains close to the caregiver in order to receive necessary care for survival. Second, the quality of attachment and its associated sensory stimuli organize the brain to define the infant's cognitive and emotional development. Here we present attachment within an historical view and highlight the importance of integrating human and animal research in understanding infant care.     

Effective medical education: insights from the Cochrane Library

In 2006, the Accreditation Council for Continuing Medical Education highlighted the need for linking educational activities to changes in competence, performance, or patient outcomes. Hence, educational providers increasingly need to know what strategies are effective. The Cochrane Library is widely regarded as the best source of credible evidence concerning health care. The authors searched the Cochrane Database of Systematic Reviews (issue 4 for 2006) using the search terms "continuing medical education," "medical education," and "continuing education." They conducted a second complementary search of this database by review group (Effective Practice and Organization of Care). Finally, the authors examined the references of recent review articles for Cochrane reviews and found 9 relevant reviews. The most effective educational methods were the most interactive. Combined didactic presentations and workshops were more effective than traditional didactic presentations alone. Medical education was more effective when more than 1 intervention occurred, especially if these interventions occurred over an extended period. Targeted education should focus on changing a behavior that is simple, because effect size is inversely proportional to the complexity of the behavior. In the era of evidence-based medicine, interventions-including educational ones-should reflect the best available evidence. Cochrane reviews of randomized controlled trials of educational methods provide important guidance that often challenges traditional didactic approaches. Integrating the findings from the Cochrane reviews may allow continuing medical education to be more successful in bringing about changes to healthcare providers' behavior. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to explain the scientific evidence concerning the effectiveness of various techniques used for continuing medical education, state the relative value of such techniques as traditional didactic lectures, conferences led by local opinion leaders, interactive workshops, and educational outreach visits, and identify the value and limitations of teaching critical appraisal skills.     

Trends in the NICU: a review of 25 years' experience

A review of 25,448 admissions was performed to evaluate the progress of neonatal intensive care at Weill Cornell Medical Center since 1978. Patients were identified by a review of admission and discharge data compiled by admitting staff. The following data were collected: birth weight, gestational age, place of birth (inborn versus outborn), discharge date, disposition. Length of stay was computed from these data. Data were organized according to year of admission. Admissions remained relatively constant with time. However the percentage of inborn infants steadily increased. Survival of the smallest infants (<600 g) remained poor, but overall survival of all infants improved over time. Length of stay for infants 1000 to 2000 g fell over time while that of other infants remained constant. These trends reflect changes in obstetric and neonatal practice over time, and include improved methods of antenatal care, neonatal pulmonary care, and nutrition, as well as changes in the distribution of neonatal and high-risk maternal care.     

The molecular pathophysiology of bacterially induced preterm labor: insights from the murine model

Premature delivery, the most important problem in obstetrics in developed countries, continues to vex clinicians and researchers. Despite decades of investigation, the pathophysiology of premature labor is incompletely understood, and therapies or preventive strategies tailored to each of the many potential causes do not exist. The present review addresses one cause of prematurity, namely, intrauterine bacterial infection. Given the vastness of the literature for even this single etiology, we focus on the mouse as a model organism from which much can be learned about mammalian parturition. The underpinnings of bacterially induced labor are believed to involve a signaling cascade that begins with recognition of offending pathogens by cell-surface receptors (toll-like receptors). This cascade then operates through multiple branching and redundant pathways to bring about the changes within the gestational compartment that produce cervical ripening, labor, and ultimately delivery. The major challenge facing researchers is to understand the levels of complexity in the host response, so that prevention and treatment strategies may be sufficiently focused to minimize unwanted side effects, yet sufficiently broad to be effective. Given the complexity of the problem, this understanding can be aided by efficient model systems, of which one in vivo example is the mouse, an organism that shares with humans many similarities in the biochemical and molecular aspects of inflammation-induced preterm labor. We propose that tools with the power to assess simultaneously the myriad elements of the hypothesized signaling cascade (ie, genomic and proteomic technologies) are important components of the solution to the puzzle of parturition.