Maternal Reports of Preterm and Sick Term Infants' Settling, Sleeping and Feeding in the 9 Months after Discharge from Neonatal Nursery: An Observational Study.

The effects of preterm birth, neonatal morbidities and environmental influences on infant sleep development is an important yet under-researched topic, with little known about normative sleep for infants born sick or preterm. The aim of this prospective, observational longitudinal study was to evaluate maternal perceptions and degree of bother with infant sleep behaviours and feeding outcomes across the first 9 months after discharge for sick/preterm infants cared for in the neonatal intensive care unit (NICU) and for healthy term-born infants. This paper reports outcomes for the sick/preterm cohort (I = 94) that were recruited from two NICUs in Perth, Western Australia. Total bother scores were on average 20.2% higher at 9 months than at two weeks post-discharge (p < 0.001). Increased night waking frequency, evening settling duration and crying duration were all positively associated with total bother scores. Maternal confidence scores were negatively associated with maternal bother scores; with each unit increase in confidence, maternal bother decreased by 8.5% (p < 0.001). Covariates such as birth gestation, breastfeeding status and multiple births were not associated with maternal bother. Families may benefit from additional support when experiencing increased night waking frequency and crying and settling durations in the first 9 months after discharge from NICU.

Australian Women's Experiences of Establishing Breastfeeding after Caesarean Birth.

Breastfeeding exclusivity and duration rates are lower after caesarean birth, yet the factors contributing to these are not well understood. This mixed-methods study used an anonymous online questionnaire to examine the facilitators and barriers to establishing breastfeeding as identified by Australian women after a caesarean birth. Quantitative data were reported using descriptive statistics, and multivariable models were used to determine the factors associated with breastfeeding outcomes including the timing of breastfeeding initiation, birth experience, and commercial infant formula use. Qualitative data were analysed using an inductive thematic analysis. Data were obtained for N = 961 women, of which <50% reported skin-to-skin contact during breastfeeding initiation. The barriers to breastfeeding included aspects of clinical care and reduced mobility, while unrushed care, partner support, and physical help with picking up the baby were helpful. Following a non-elective caesarean birth, women had half the odds of early breastfeeding initiation (OR = 0.50; 95% CI: 0.36, 0.68; p ≤ 0.001) and 10 times the odds to report a negative birth experience (OR = 10.2; 95% CI: 6.88, 15.43; p < 0.001). Commercial milk formula use was higher in primiparous women (OR = 2.16; 95% CI: 1.60, 2.91; p < 0.001) and in those that birthed in a private hospital (OR = 1.67; 95% CI: 1.25, 2.32; p = 0.001). Pain and reduced mobility, as well as conflicting and rushed care, negatively impacted breastfeeding after a caesarean birth, while delayed breastfeeding initiation, higher pain ratings, and negative birth experiences were more common for women that birthed by non-elective caesarean. This study adds valuable insights into the physical, emotional, and clinical care needs of women in establishing breastfeeding after a surgical birth. Clinical staffing and care should be modified to include full access to partner support to meet the specific needs of breastfeeding women after a caesarean birth.

Inflammation risk before cardiac surgery and the treatment effect of intraoperative dexamethasone.

Patients who exhibit high systemic inflammation after cardiac surgery may benefit most from pre-emptive anti-inflammatory treatments. In this secondary analysis (n = 813) of the randomised, double-blind Intraoperative High-Dose Dexamethasone for Cardiac Surgery trial, we set out to develop an inflammation risk prediction model and assess whether patients at higher risk benefit from a single intraoperative dose of dexamethasone (1 mg/kg). Inflammation risk before surgery was quantified from a linear regression model developed in the placebo arm, relating preoperatively available covariates to peak postoperative C-reactive protein. The primary endpoint was the interaction between inflammation risk and the peak postoperative C-reactive protein reduction associated with dexamethasone treatment. The impact of dexamethasone on the main clinical outcome (a composite of death, myocardial infarction, stroke, renal failure, or respiratory failure within 30 days) was also explored in relation to inflammation risk. Preoperatively available covariates explained a minority of peak postoperative C-reactive protein variation and were not suitable for clinical application (R2 = 0.058, P = 0.012); C-reactive protein before surgery (excluded above 10 mg/L) was the most predictive covariate (P < 0.001). The anti-inflammatory effect of dexamethasone increased as the inflammation risk increased (-0.689 mg/L per unit predicted peak C-reactive protein, P = 0.002 for interaction). No treatment-effect heterogeneity was detected for the main clinical outcome (P = 0.167 for interaction). Overall, risk predictions from a model of inflammation after cardiac surgery were associated with the degree of peak postoperative C-reactive protein reduction derived from dexamethasone treatment. Future work should explore the impact of this phenomenon on clinical outcomes in larger surgical populations.

Localisation accuracy with iodine-125 seed versus wire guidance for breast cancer surgery.

INTRODUCTION: Impalpable breast lesions generally require image-guided localisation for breast-conserving surgery. A standard technique is to place a hook wire (HW) within the lesion. Radioguided occult lesion localisation using iodine seeds (ROLLIS) involves inserting a 4.5 mm iodine-125 seed (seed) into the lesion. We hypothesised that a seed could be more precisely positioned in relation to the lesion than a HW and that this may be associated with a lower re-excision rate. METHODS: Retrospective review of consecutive participant data from three ROLLIS RCT (ACTRN12613000655741) sites. Participants underwent preoperative lesion localisation (PLL) with seed or HW between September 2013 and December 2017. Lesion and procedural characteristics were recorded. Distances between (1) any part of the seed or thickened segment of the HW ('TSHW') and the lesion/clip ('distance to device' DTD) and (2) centre of the TSHW/seed and centre of the lesion/clip (device centre to target centre 'DCTC') were measured on immediate postinsertion mammograms. Pathological margin involvement and re-excision rates were compared. RESULTS: A total of 390 lesions (190 ROLLIS and 200 HWL) were analysed. Lesion characteristics and guidance modality used were similar between groups. Ultrasound-guided DTD and DCTC for seed were smaller than for HW (77.1% and 60.6%, respectively, P-value < 0.001). Stereotactic-guided DCTC for seeds was 41.6% smaller than for HW (P-value = 0.001). No statistically significant difference in the re-excision rates was found. CONCLUSION: Iodine-125 seeds can be more precisely positioned for preoperative lesion localisation than HW, however, no statistically significant difference in re-excision rates was detected.

Quality of life after stenting for chronic iliocaval obstruction.

BACKGROUND: Iliocaval stenting is widely used for treatment of symptomatic iliocaval obstruction. The aim of our study was to compare quality of life before and after iliocaval stenting. METHOD: Prospectively collected data using CIVIQ20 questionnaire, Venous Clinical Severity Score (rVCSS) and Villalta-Prandoni score (VP) of patients following iliocaval stenting for non-thrombotic and post-thrombotic venous obstruction were analysed. RESULT: One hundred and one limbs (87 patients) were stented between May 2017 and May 2019. Baseline CIVIQ20 median value was 50 (34-66); 1 month after surgery CIVIQ20 value was 36 (26-58) and the scores then remained steady for the rest of the first year. Both rVCSS and VP scores decrease by 3.09 (95% CI: 2.39, 3.89; p < .001) and 5.21 (95% CI: 4.14, 6.48; p < .001) units, respectively, throughout the first year. CONCLUSION: Quality of life of patients with iliocaval obstruction significantly improves after successful percutaneous reconstruction. Severity of symptoms measured by rVCSS and VP scores decreases.

A randomised controlled trial of succinylated gelatin (4%) fluid on urinary acute kidney injury biomarkers in cardiac surgical patients.

BACKGROUND: Fluid resuscitation is frequently required for cardiac surgical patients admitted to the intensive care unit. The ideal fluid of choice in regard to efficacy and safety remains uncertain. Compared with crystalloid fluid, colloid fluid may result in less positive fluid balance. However, some synthetic colloids are associated with increased risk of acute kidney injury (AKI). This study compared the effects of succinylated gelatin (4%) (GEL) with compound sodium lactate (CSL) on urinary AKI biomarkers in patients after cardiac surgery. METHODS: Cardiac surgical patients who required an intravenous fluid bolus of at least 500 mL postoperatively were randomly allocated to receive GEL or CSL as the resuscitation fluid of choice for the subsequent 24 h. Primary outcomes were serial urinary neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C concentrations measured at baseline, 1 h, 5 h and 24 h after enrolment, with higher concentrations indicating greater kidney injury. Secondary biomarker outcomes included urinary clusterin, α1-microglobulin and F2-isoprostanes concentrations. Differences in change of biomarker concentration between the two groups over time were compared with mixed-effects regression models. Statistical significance was set at P < 0.05. RESULTS: Forty cardiac surgical patients (n = 20 per group) with similar baseline characteristics were included. There was no significant difference in the median volume of fluid boluses administered over 24 h between the GEL (1250 mL, Q1-Q3 500-1750) and CSL group (1000 mL, Q1-Q3 500-1375) (P = 0.42). There was a significantly greater increase in urinary cystatin C (P < 0.001), clusterin (P < 0.001), α1-microglobulin (P < 0.001) and F2-isoprostanes (P = 0.020) concentrations over time in the GEL group, compared to the CSL group. Change in urinary NGAL concentration (P = 0.68) over time was not significantly different between the groups. The results were not modified by adjustment for either urinary osmolality or EuroSCORE II predicted risk of mortality. CONCLUSIONS: This preliminary randomised controlled trial showed that use of succinylated gelatin (4%) for fluid resuscitation after cardiac surgery was associated with increased biomarker concentrations of renal tubular injury and dysfunction, compared to crystalloid fluid. These results generate concern that use of intravenous gelatin fluid may contribute to clinically relevant postoperative AKI. Trial registration ANZCTR.org.au, ACTRN12617001461381. Registered on 16th October, 2017, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373619&isReview=true .

A Randomized Controlled Trial on the Effects of a 6-Month Home-Based Physical Activity Program with Individual Goal-Setting and Volunteer Mentors on Physical Activity, Adherence, and Physical Fitness in Inactive Older Adults at Risk of Cognitive Decline: The INDIGO Study.

BACKGROUND: Increasing physical activity (PA) in those who have memory concerns requires innovative approaches. OBJECTIVE: To compare in this randomized controlled trial (RCT) the effects on PA, adherence, and fitness of two approaches to deliver a 6-month home-based PA program in older, inactive individuals at risk of cognitive decline. METHODS: Individuals (n = 52) aged 60-85 years, inactive with mild cognitive impairment or subjective cognitive decline were recruited from the community and memory clinics. Randomization was to 6 months of 150 min/week moderate intensity PA with either: goal-setting with mentor support; or education and peer contact. A subset of participants (n = 36) continued for a further 6 months. PA, moderate and vigorous PA, and secondary outcomes, fitness, goal performance/satisfaction and self-efficacy were assessed at baseline, 6 and 12 months. Modelling of primary and secondary outcomes was conducted with linear mixed models. RESULTS: Participants were mean age (±sd) 70.1 (6.4) years. Six-month retention was 88.5%(n = 46). No significant between-group differences were observed for PA or fitness. Post-hoc combined group data showed a significant, moderate-large effect size increase in PA with time. PA increased by a mean 1,662 (943, 2383) steps/day (95%CI) and 1,320 (603, 2037) steps/day at 6 and 12 months (p < 0.001). Median (quartiles Q1-Q3) 6 and 6-12 month combined group adherence was 88.9 (74.4-95.7)%and 84.6 (73.9-95.4)%respectively. CONCLUSION: In this target group, no differences were detected between groups both intervention strategies were highly effective in increasing PA and fitness.

Artifacts in contrast-enhanced mammography: are there differences between vendors?

PURPOSE: Contrast-Enhanced Mammography (CEM) produces a dual-energy subtracted (DES) image that demonstrates iodine uptake (neovascularity) in breast tissue. We aim to review a range of artifacts on DES images produced using equipment from two different vendors and compare their incidence and subjective severity. METHODS: We retrospectively reviewed CEM studies performed between September 2013 and March 2017 using GE Senographe Essential (n = 100) and Hologic Selenia Dimensions (n = 100) equipment. Artifacts were categorized and graded in severity by a subspecialist breast radiologist and one of two medical imaging technologists in consensus. The incidence of artifacts between vendors was compared by calculating the relative risk, and the severity gradings were compared using a Wilcoxon rank-sum test. RESULTS: Elephant rind, corrugations and the black line on chest wall artifact were seen exclusively in Hologic images. Artifacts such as cloudy fat, negative rim around lesion and white line on pectoral muscle were seen in significantly more Hologic images (p < 0.05) whilst halo, ripple, skin line enhancement, black line on pectoral muscle, bright pectorals, chest wall high-lighting and air gap were seen in significantly more GE images (p < 0.05). The severity gradings for cloudy fat had a significantly higher mean rank in Hologic images (p < 0.001) whilst halo and ripple artifacts had a significantly higher mean rank in GE images (p < 0.001 and p = 0.028 respectively). CONCLUSION: The type, incidence and subjective severity of CEM-specific artifacts differ between vendors. Further research is needed, but differences in algorithms used to produce the DE image are postulated to be a significant contributor.

Within-unit bed moves in a short-stay in-patient unit are associated with increased falls.

Objective This study evaluated a patient's likelihood of a fall using information available at the time of presentation to a short-stay acute medical unit (AMU) with a high patient turnover rate and estimated the effect of within-unit bed moves on the occurrence of in-patient falls. Methods This study was a 3-year retrospective cross-sectional study of 28713 consecutive admissions comparing patients who fell and patients who did not fall. Factors assessed included premorbid falls risk factors, presenting issues and within-unit bed moves. Logistic regression was used to identify factors associated with patients who fell. Each admission was treated as a unit of measure. Results Of 28713 admissions, 182 (0.6%) involved at least one fall event. The fall rate was 5.67 falls per 1000 occupied bed days. Premorbid cognitive impairment (odds ratio (OR) 4.88), a presenting issue of confusion (OR 2.92) and a fall immediately before admission (OR 2.49) were associated with patients who fell (all P<0.001). Each bed move corresponded to a 27% increase in the odds of a fall (OR 1.27; P=0.027). Conclusion Premorbid cognitive impairment was the strongest risk factor for an in-patient fall on the unit. Within-unit bed moves significantly increased the risk of an in-patient fall and should be minimised. What is known about the topic? In-patient falls can cause significant patient harm at cost to the health system. There is limited research examining the association between within-unit bed moves and falls in a short-stay AMU. What does this paper add? Care in the short-stay AMU is complex and the number of bed moves is a modifiable factor that can reduce a patient's risk of an in-patient fall. What are the implications for practitioners? Bed moves need to be minimised, especially for patients with cognitive impairment. If bed moves are inevitable, operational plans can be designed to mitigate the increased risk caused by these moves.

Are breast biopsy markers underused?

INTRODUCTION: To evaluate current use of breast biopsy markers (BBM) amongst Australian and New Zealand radiologists. METHODS: Radiologists attending a national breast conference were invited to complete an online survey addressing demographics, BBM use following ultrasound, stereotactic, tomosynthesis and MRI-guided biopsy, frequency of early BBM displacement, preoperative lesion localisation (PLL) and axillary BBM use. RESULTS: Overall response rate was 52% (60/115). The majority (n = 45) 75% practiced in Australia. 98% had BBMs available in their practice, 40% reported BBM costs weren't covered by insurance. 27% would use BBMs more often if they were, with some utilising smaller gauge devices for lesion sampling to minimise need for BBM use and patient out-of-pocket costs. Ultrasound-guided procedures were associated with lower rates of clinically significant BBM displacement (P = 0.001). Considering PLL, 44% were able to perform US-guided PLL in <25% of cases. Poor sonographic visibility was the commonest reason why this wasn't possible. In the axilla, BBMs were mainly used to mark positive nodes in pre-neoadjuvant chemotherapy patients. CONCLUSION: This survey is the first to provide data on BBM use amongst a sample of predominantly Australian and New Zealand radiologists, and provides compelling evidence of significantly lower incidence of BBM displacement with US-guided procedures. Our results suggest some radiologists may hesitate to use BBMs due to cost, and this can influence their choice of biopsy technique. Provision of a Medicare item Number for BBMs may lead to increased adoption of best practice guidelines for preoperative diagnosis of breast lesions.

Front-of-neck airway rescue with impalpable anatomy during a simulated cannot intubate, cannot oxygenate scenario: scalpel-finger-cannula versus scalpel-finger-bougie in a sheep model.

BACKGROUND: Front-of-neck airway rescue in a cannot intubate, cannot oxygenate (CICO) scenario with impalpable anatomy is particularly challenging. Several techniques have been described based on a midline vertical neck incision with subsequent finger dissection, followed by either a cannula or scalpel puncture of the now palpated airway. We explored whether the speed of rescue oxygenation differs between these techniques. METHODS: In a high-fidelity simulation of a CICO scenario in anaesthetised Merino sheep with impalpable front-of-neck anatomy, 35 consecutive eligible participants undergoing airway training performed scalpel-finger-cannula and scalpel-finger-bougie in a random order. The primary outcome was time from airway palpation to first oxygen delivery. Data, were analysed with Cox proportional hazards. RESULTS: Scalpel-finger-cannula was associated with shorter time to first oxygen delivery on univariate (hazard ratio [HR]=11.37; 95% confidence interval [CI], 5.14-25.13; P<0.001) and multivariate (HR=8.87; 95% CI, 4.31-18.18; P<0.001) analyses. In the multivariable model, consultant grade was also associated with quicker first oxygen delivery compared with registrar grade (HR=3.28; 95% CI, 1.36-7.95; P=0.008). With scalpel-finger-cannula, successful oxygen delivery within 3 min of CICO declaration and ≤2 attempts was more frequent; 97% vs 63%, P<0.001. In analyses of successful cases only, scalpel-finger-cannula resulted in earlier improvement in arterial oxygen saturations (-25 s; 95% CI, -35 to -15; P<0.001), but a longer time to first capnography reading (+89 s; 95% CI, 69 to 110; P<0.001). No major complications occurred in either arm. CONCLUSIONS: The scalpel-finger-cannula technique was associated with superior oxygen delivery performance during a simulated CICO scenario in sheep with impalpable front-of-neck anatomy.

Towards the Development of an Integrative, Evidence-Based Suite of Indicators for the Prediction of Outcome Following Mild Traumatic Brain Injury: Results from a Pilot Study.

BACKGROUND: Persisting post-concussion symptoms (PPCS) is a complex, multifaceted condition in which individuals continue to experience the symptoms of mild traumatic brain injury (mTBI; concussion) beyond the timeframe that it typically takes to recover. Currently, there is no way of knowing which individuals may develop this condition. METHOD: Patients presenting to a hospital emergency department (ED) within 48 h of sustaining a mTBI underwent neuropsychological assessment and demographic, injury-related information and blood samples were collected. Concentrations of blood-based biomarkers neuron specific enolase, neurofilament protein-light, and glial fibrillary acidic protein were assessed, and a subset of patients also underwent diffusion tensor-magnetic resonance imaging; both relative to healthy controls. Individuals were classified as having PPCS if they reported a score of 25 or higher on the Rivermead Postconcussion Symptoms Questionnaire at ~28 days post-injury. Univariate exact logistic regression was performed to identify measures that may be predictive of PPCS. Neuroimaging data were examined for differences in fractional anisotropy (FA) and mean diffusivity in regions of interest. RESULTS: Of n = 36 individuals, three (8.33%) were classified as having PPCS. Increased performance on the Repeatable Battery for the Assessment of Neuropsychological Status Update Total Score (OR = 0.81, 95% CI: 0.61-0.95, p = 0.004), Immediate Memory (OR = 0.79, 95% CI: 0.56-0.94, p = 0.001), and Attention (OR = 0.86, 95% CI: 0.71-0.97, p = 0.007) indices, as well as faster completion of the Trails Making Test B (OR = 1.06, 95% CI: 1.00-1.12, p = 0.032) at ED presentation were associated with a statistically significant decreased odds of an individual being classified as having PPCS. There was no significant association between blood-based biomarkers and PPCS in this small sample, although glial fibrillary acidic protein (GFAP) was significantly increased in individuals with mTBI relative to healthy controls. Furthermore, relative to healthy age and sex-matched controls (n = 8), individuals with mTBI (n = 14) had higher levels of FA within the left inferior frontal occipital fasciculus (t (18.06) = -3.01, p = 0.008). CONCLUSION: Performance on neuropsychological measures may be useful for predicting PPCS, but further investigation is required to elucidate the utility of this and other potential predictors.

The effect of implant modification: the low contact stress experience.

AIMS: The aim of this study was to conduct the largest low contact stress (LCS) retrieval study to elucidate the failure mechanisms of the Porocoat and Duofix femoral component. The latter design was voluntarily recalled by the manufacturer. MATERIALS AND METHODS: Uncemented LCS explants were divided into three groups: Duofix, Porocoat, and mixed. Demographics, polyethylene wear, tissue ingrowth, and metallurgical analyses were performed. RESULTS: In 104 implants, a decrease in the odds of loosening and an increase in metallosis and tissue staining in the Duofix group relative to Porocoat group was detected (p = 0.028). There was an increased presence of embedded metallic debris in the Duofix group (p < 0.001). Decreased tissue ingrowth was associated with the Duofix surface (p < 0.001). The attached beads had reduced microhardness, indicative of adverse thermal processing, which resulted in bead shedding, particulate debris, and metallosis. CONCLUSION: Hydroxyapatite coating of the LCS femoral component produced unexpected results and led to its recall. The root cause was likely a combination of retained alumina grit and a reduction in bead microhardness (mechanical strength) resulting in increased particle debris, metallosis, and early revision. The Duofix LCS femoral component was not equivalent to the Porocoat version despite its approval through the Food and Drug Administration (FDA) 510(k) equivalance approval process. Regulation of the introduction of modified existing devices needs to be improved and the Duofix LCS should have been considered to be a new device for which equivalence had not been demonstrated at the point of introduction. Cite this article: Bone Joint J 2019;101-B:1248-1255.