Optimising recovery after perineal trauma: Implementation of an evidence-based patient-centred care and clinical practice guideline.

BACKGROUND: Perineal trauma and pain can affect the quality of life of women who experience vaginal birth. AIM: To investigate the effect of perineal care and pain management on women's postpartum recovery. METHODS: This was a Quasi-experimental study. In Phase 1 women were treated using our old postnatal perineal care management guideline. In Phase 2 an updated guideline was introduced (regular administration of icepacks and analgesia during the first 24-48 h postpartum). During Phase 1, pregnant women planning a vaginal birth completed a baseline questionnaire. Those who sustained perineal trauma completed a survey at 24-48 h, seven days and 12 weeks after birth. In Phase 2 we continued recruiting participants, using the same procedure, and investigated the efficacy of pain relief approaches using the new guideline. RESULTS: In Phase 1, 111 women (Group 1), and Phase 2, 146 women (Group 2) were recruited. No statistically significant differences were found between the two groups in terms of the women's pain catastrophising, their partner's responses to pain behaviours, or birth outcomes. At 24-48 h and seven days postpartum, women in Group 2 were less likely than women in Group 1 to be bothered by back or perineal pain, headache, sleeping difficulties and dizziness (p < 0.05). More women in Group 2 received regular paracetamol and perineal icepacks during their hospital stay, with less use of oxycodone in Group 2 than Group 1. CONCLUSION: The implementation of the guideline's recommendations was associated with decrease back and perineal pain, headache, sleeping difficulties and dizziness during the first seven days postpartum.

Implementing an evidence-based guideline to decrease opioids after cardiac surgery.

BACKGROUND: Deaths related to overdoses continue growing in the United States. The overprescription of opioids after surgical procedures may contribute to this problem. LOCAL PROBLEM: There is inconsistency in the prescription of opioids in cardiovascular surgery patients. Recommendations regarding the reduction of opioids at discharge are not fully implemented. METHODS: This is a single-center, pre-post quality improvement project in adult patients after elective cardiac surgery through sternotomy. INTERVENTIONS: Changes in guidelines, modification of order sets, creation of dashboards, and education to the providers to increase the prescription of acetaminophen around the clock on the step-down unit and at discharge, decrease the number of opioid tablets to 25 or less at discharge and decrease the prescription of opioids to 25 or less morphine milligram equivalents (MME) at discharge. RESULTS: The preintervention group included 67 consecutive patients who underwent cardiac surgery from November to December 2021. The postintervention group had 67 patients during the same period in 2022. Acetaminophen prescription on the step-down unit increased from 9% to 96% ( p < .001). The proportion of patients discharged with 25 or less opioid tablets increased from 18% to 90% ( p < .001) and with 25 or less MME from 30% to 55% ( p < .01). Acetaminophen prescription at discharge increased from 10% to 48% ( p < .001). CONCLUSIONS: Our intervention increased the use of acetaminophen and decreased the overprescription of opioids in cardiac surgery patients at discharge. Further research is necessary to continue improving pain management to reduce the number of opioids prescribed at discharge.

Women's experience of perinatal support in a high migrant Australian population during the COVID-19 pandemic: a mixed methods study.

BACKGROUND: As a COVID-19 risk mitigation measure, Australia closed its international borders for two years with significant socioeconomic disruption including impacting approximately 30% of the Australian population who are migrants. Migrant populations during the peripartum often rely on overseas relatives visiting for social support. High quality social support is known to lead to improved health outcomes with disruption to support a recognised health risk. AIM: To explore women's experience of peripartum social support during the COVID-19 pandemic in a high migrant population. To quantify type and frequency of support to identify characteristics of vulnerable perinatal populations for future pandemic preparedness. METHODS: A mixed methods study with semi-structured interviews and a quantitative survey was conducted from October 2020 to April 2021. A thematic approach was used for analysis. RESULTS: There were 24 participants interviewed both antenatally and postnatally (22 antenatal; 18 postnatal). Fourteen women were migrants and 10 Australian born. Main themes included; 'Significant disruption and loss of peripartum support during the COVID-19 pandemic and ongoing impact for migrant women'; 'Husbands/partners filling the support gap' and 'Holding on by a virtual thread'. Half of the participants felt unsupported antenatally. For Australian born women, this dissipated postnatally, but migrants continued to feel unsupported. Migrant women discussed partners stepped into traditional roles and duties of absent mothers and mothers-in-law who were only available virtually. CONCLUSION: This study identified disrupted social support for migrant women during the pandemic, providing further evidence that the pandemic has disproportionately impacted migrant populations. However, the benefits identified in this study included high use of virtual support, which could be leveraged for improving clinical care in the present and in future pandemics. The COVID-19 pandemic impacted most women's peripartum social support with migrant families having ongoing disruption. Gains in the pandemic included greater gender equity for domestic work as husbands/partners increased their contribution to domestic work and childcare.

Perioperative management of P2Y12 inhibitors in patients undergoing cardiac surgery within 1 year of PCI.

AIMS: To evaluate the impact of perioperative P2Y12 receptor inhibitor therapy among patients undergoing cardiac surgery within 1 year of percutaneous coronary intervention (PCI). METHODS AND RESULTS: Patients undergoing cardiac surgery in the year post-PCI at three tertiary care centres between 2011 and 2018 were stratified into those who had received at least one dose of P2Y12 inhibitor prior to surgery (within 5 days for clopidogrel or prasugrel, or within 3 days for ticagrelor) and those who had not. The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCEs) and bleeding. Among 20 279 PCI patients, 359 (1.8%) underwent cardiac surgery in the ensuing year, 76.3% of whom received coronary artery bypass grafts. Overall, 33 (9.2%) MACCEs and 85 (23.7%) bleeding events occurred within 30 days post-cardiac surgery. Perioperative P2Y12 inhibition (N = 133, 37%) was not associated with the risk of MACCEs or bleeding, despite numerically lower rates of myocardial infarction or stent thrombosis (0.0% vs. 2.6%; P = 0.089). Patients who continued the P2Y12 inhibitor until the day of surgery (N = 60, 17%) had significantly higher bleeding risk [adjusted odds ratio 2.93, 95% confidence interval 1.53-5.59)]. Predictors of MACCEs included a time interval from PCI to cardiac surgery of ≤30 days and reduced ejection fraction, whereas urgent/emergent surgery predicted bleeding. Chronic kidney disease and myocardial infarction as indication for PCI predicted both MACCEs and bleeding. CONCLUSION: Among patients undergoing cardiac surgery in the year after PCI, the perioperative risk of ischaemic and bleeding events might be influenced by P2Y12 inhibitor therapy in addition to other risk parameters, including the timing and urgency of the procedure.

Exploring the COVID-19 pandemic experience of maternity clinicians in a high migrant population and low COVID-19 prevalence country: A qualitative study.

BACKGROUND: Australia experienced a low prevalence of COVID-19 in 2020 compared to many other countries. However, maternity care has been impacted with hospital policy driven changes in practice. Little qualitative research has investigated maternity clinicians' perception of the impact of COVID-19 in a high-migrant population. AIM: To investigate maternity clinicians' perceptions of patient experience, service delivery and personal experience in a high-migrant population. METHODS: We conducted semi-structured in-depth interviews with 14 maternity care clinicians in Sydney, New South Wales, Australia. Interviews were conducted from November to December 2020. A reflexive thematic approach was used for data analysis. FINDINGS: A key theme in the data was 'COVID-19 related travel restrictions result in loss of valued family support for migrant families'. However, partners were often 'stepping-up' into the role of missing overseas relatives. The main theme in clinical care was a shift in healthcare delivery away from optimising patient care to a focus on preservation and safety of health staff. DISCUSSION: Clinicians were of the view migrant women were deeply affected by the loss of traditional support. However, the benefit may be the potential for greater gender equity and bonding opportunities for partners. Conflict with professional beneficence principles and values may result in bending rules when a disconnect exists between relaxed community health orders and restrictive hospital protocols during different phases of a pandemic. CONCLUSION: This research adds to the literature that migrant women require individualised culturally safe care because of the ongoing impact of loss of support during the COVID-19 pandemic.

Comparing JM-105 and MBJ-20 Transcutaneous Bilirubinometers According to the Area Tested in Ethnically Diverse Late-Preterm and Term Neonates.

This study aims to evaluate the correlation between the results of transcutaneous bilirubin (TcB) levels measured by the 2 transcutaneous bilirubinometers according to the area tested and to compare the TcB measurements and the serum bilirubin (SBR) levels. We screened 78 neonates born at more than 35 weeks of gestation and aged less than 168 hours for jaundice. We used JM-105 and MBJ-20 to measure the TcB at the forehead and the chest. For newborns who had high TcB measurements, we obtained blood samples during the subsequent 30 minutes. There was a strong correlation between the TcB measurements by JM-105 and MBJ-20 and this correlation was stronger when they were used on the sternum. The mean differences between the TcB measurements on the forehead and the sternum and the SBR levels were similar for the JM-105 and the MBJ-20. There was a strong correlation between SBR and the measurements using the 2 devices on the sternum (JM-105: r = 0.805; MBJ-20: r = 0.801), unlike measurements taken on the forehead by each device (r = 0.777 and r = 0.751, respectively). Both devices had high sensitivity and negative predictive values at SBR level of less than 230 µmol/L (<13.4 mg/dL) and high specificity and positive predictive values at SBR level of 230 µmol/L and greater (>13.4mg/dL). Both devices equally overestimated the actual SBR and had more reliable results if used on the sternum.

The "Ice Age" in Cardiac Surgery: Evolution of the "Siberian" Method of Brain Protection During Deep Hypothermic Perfusionless Circulatory Arrest.

Deep hypothermic perfusionless circulatory arrest was the first practical neuroprotective technique used for open-heart surgery. It was refined at the Novosibirsk Medical Research Center in Siberia and was actively used from the mid-1950s until 2001.This review describes the development of this technique and its contribution to our understanding of the dynamic changes in human physiology during induced hypothermia for circulatory arrest without extracorporeal perfusion. Deep hypothermic perfusionless circulatory arrest was an important stepping stone in the development of modern approaches in neuroprotection and monitoring during cardiac surgery.

Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis.

The VARC (Valve Academic Research Consortium) for transcatheter aortic valve replacement set the standard for selecting appropriate clinical endpoints reflecting safety and effectiveness of transcatheter devices, and defining single and composite clinical endpoints for clinical trials. No such standardization exists for circumferentially sutured surgical valve paravalvular leak (PVL) closure. This document seeks to provide core principles, appropriate clinical endpoints, and endpoint definitions to be used in clinical trials of PVL closure devices. The PVL Academic Research Consortium met to review evidence and make recommendations for assessment of disease severity, data collection, and updated endpoint definitions. A 5-class grading scheme to evaluate PVL was developed in concordance with VARC recommendations. Unresolved issues in the field are outlined. The current PVL Academic Research Consortium provides recommendations for assessment of disease severity, data collection, and endpoint definitions. Future research in the field is warranted.

Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis: An Expert Statement.

The VARC (Valve Academic Research Consortium) for transcatheter aortic valve replacement set the standard for selecting appropriate clinical endpoints reflecting safety and effectiveness of transcatheter devices, and defining single and composite clinical endpoints for clinical trials. No such standardization exists for circumferentially sutured surgical valve paravalvular leak (PVL) closure. This document seeks to provide core principles, appropriate clinical endpoints, and endpoint definitions to be used in clinical trials of PVL closure devices. The PVL Academic Research Consortium met to review evidence and make recommendations for assessment of disease severity, data collection, and updated endpoint definitions. A 5-class grading scheme to evaluate PVL was developed in concordance with VARC recommendations. Unresolved issues in the field are outlined. The current PVL Academic Research Consortium provides recommendations for assessment of disease severity, data collection, and endpoint definitions. Future research in the field is warranted.

A translational "humanised" porcine model for transcatheter mitral valve interventions: the neo inferior vena cava approach.

AIMS: Preclinical studies and translational animal models are fundamental for the development of new clinical interventions. Compared to human anatomy, pigs present a more anterior heart position in the chest which may jeopardise the imaging and testing of devices designed to be delivered to the human mitral valve. To imitate human anatomy, we developed a novel model to "humanise" a pig heart. METHODS AND RESULTS: The creation of a neo inferior vena cava with a Dacron tube grafted to the right atrium was tested for transseptal delivery of an experimental mitral annuloplasty device in 35 animals. In 15 animals with native anatomy a conventional right transfemoral access was used. Imaging guidance was achieved with intracardiac or epicardial echocardiography. In all transfemoral approaches (n=15), the delivery of the device was unsuccessful and the handling was dissimilar to a human implant. In all neo-cava approaches (n=35), the handling and manoeuvring were as expected in humans, the targets were reached as intended and all procedures but one were successful. CONCLUSIONS: A translational "humanised" animal model with the creation of a neo cava eliminates the differences between pig and human anatomy and is suitable for testing human grade devices.

The decision to suture after childbirth: cues, related factors, knowledge and experience used by midwives.

OBJECTIVE: to present critical cues, related factors, knowledge and experience used by midwives when deciding whether or not to suture perineal and associated trauma after childbirth. DESIGN: an exploratory descriptive study using in-depth interviews to collect data using the Critical Decision Method. SETTING: birth units in Greater Western Sydney. PARTICIPANTS: 19 volunteer midwives experienced in deciding whether or not to suture or in making referrals to suture childbirth trauma. FINDINGS: the main findings were the cues of bleeding and trauma with their accompanying specific attributes, and woman- and midwife-centred factors considered when deciding whether or not to suture perineal and associated trauma. Furthermore, the knowledge and experience that supported decision-making, such as detailed knowledge of anatomical structures, workshops and observing highly skilled clinicians, were identified. CONCLUSION: the cues and related factors can be formed into an inventory and tested for content validity using a panel of expert midwives. IMPLICATIONS FOR PRACTICE: such an inventory has the potential to minimise inappropriate intervention and alleviate unnecessary discomfort, thus increasing safety and quality of care for women following childbirth. In addition, midwifery educators and those coaching less-experienced midwives can use the collected clinical information to aid the development of students' and midwives' decision-making skills regarding whether or not to suture childbirth trauma.

Clinical decision-making for repair of spontaneous childbirth trauma: validation of cues and related factors.

From recalled childbirth cases, a series of cues and related factors were previously identified that were used by midwives when making decisions to suture or not suture perineal and associated trauma incurred during spontaneous vaginal delivery. This study aimed to determine the validity of these cues and related factors. A panel of 18 experienced midwives evaluated their content validity using the criteria of "necessity" and "sufficiency." The two main cue categories-"bleeding" and "birth trauma"-were considered by 18 (100%) of the panel members to be necessary to assess. At least 16 (89%) panel members considered the following specific cues necessary to assess: in the bleeding category-type, flow, amount, and effect of application of pressure or ice; in the birth trauma category-trauma sites, trauma types, dimensions of trauma, types of tissue, alignment of tissue, edema, and bruising. Seventeen (94%) panel members considered seven woman-centred related factors that were necessary to assess and 14 (78%) considered the combination of all cues in bleeding, birth trauma, and related factors sufficient for making the decision to suture or not. The availability of these validated cues and related factors has the potential to guide a comprehensive assessment on which the decision to suture or not suture depends. This addition to the domain of midwifery knowledge enables educational preparation of midwives who will have the capacity to more adequately support women in childbirth.