RESUMO
OBJECTIVE: To decrease the incidence of postnatal growth restriction, defined as discharge weight <10th percentile for postmenstrual age, among preterm infants cared for in New York State Regional Perinatal Centers. STUDY DESIGN: The quality improvement cohort consisted of infants <31 weeks of gestation admitted to a New York State Regional Perinatal Center within 48 hours of birth who survived to hospital discharge. Using quality improvement principles from the Institute for Healthcare Improvement and experience derived from successfully reducing central line-associated blood stream infections statewide, the New York State Perinatal Quality Collaborative sought to improve neonatal growth by adopting better nutritional practices identified through literature review and collaborative learning. New York State Regional Perinatal Center neonatologists were surveyed to characterize practice changes during the project. The primary outcome-the incidence of postnatal growth restriction-was compared across the study period from baseline (2010) to the final (2013) years of the project. Secondary outcomes included differences in z-score between birth and discharge weights and head circumferences. RESULTS: We achieved a 19% reduction, from 32.6% to 26.3%, in postnatal growth restriction before hospital discharge. Reductions in the difference in z-score between birth and discharge weights were significant, and differences in z-score between birth and discharge head circumference approached significance. In survey data, regional perinatal center neonatologists targeted change in initiation of feedings, earlier breast milk fortification, and evaluation of feeding tolerance. CONCLUSIONS: Statewide collaborative quality improvement can achieve significant improvement in neonatal growth outcomes that, in other studies, have been associated with improved neurodevelopment in later infancy.
Assuntos
Desenvolvimento Infantil , Nutrição Enteral/métodos , Transtornos do Crescimento/prevenção & controle , Recém-Nascido Prematuro/crescimento & desenvolvimento , Feminino , Idade Gestacional , Transtornos do Crescimento/epidemiologia , Humanos , Incidência , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , New York , Alta do Paciente , Gravidez , Melhoria de QualidadeRESUMO
OBJECTIVE: To evaluate the magnitude, consistency, and natural history of reductions in cerebral regional tissue oxygenation (CrSO2) during umbilical arterial (UA) blood sampling in very low birth weight neonates. STUDY DESIGN: Data were collected during a prospective observational near-infrared spectroscopy survey conducted on a convenience sample of 500-1250 g neonates during the first 10 postnatal days. A before-after analysis of UA blood sampling effects on CrSO2 absolute values and variability was performed. The present analysis was not designed a priori and was conducted following the bedside observation of CrSO2 decrements contiguous with UA blood draws. RESULTS: Fifteen very low birth weight neonates had 201 UA blood draws. Baseline CrSO2 (mean ± SEM) decreased following UA blood sampling, from 70 ± 1% to a nadir of 63 ± 1% (P < .001) occurring 4 ± 3 (range 2-24) minutes following blood draws. CrSO2 subsequently increased to 70 ± 1% (P < .001 compared with nadir) at 10 ± 4 (range 4-28) minutes following UA blood sampling. Coefficients of variation (mean ± SEM) increased from 0.02 ± 0.001 at baseline to 0.05 ± 0.004 (P < .001), followed by a decrease to 0.03 ± 0.003 (P < .001 for all comparisons), thus denoting increased CrSO2 variability following UA blood sampling. CONCLUSIONS: UA blood sampling is associated with significant CrSO2 decrements with increased variability over clinically significant intervals. Whether these changes impact complications of prematurity, including intraventricular hemorrhage and periventricular leukomalacia, remain unknown.
Assuntos
Coleta de Amostras Sanguíneas/métodos , Circulação Cerebrovascular , Artérias Umbilicais/patologia , Encéfalo/fisiopatologia , Idade Gestacional , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Terapia Intensiva Neonatal , Oximetria , Oxigênio/sangue , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho , Fatores de TempoAssuntos
Aleitamento Materno , Alimentos Formulados , Fórmulas Infantis , Lactente Extremamente Prematuro , Animais , Feminino , Humanos , MasculinoRESUMO
OBJECTIVE: To determine provider compliance with protocols for the prevention of postpartum hemorrhage and provider characteristics associated with adherence and non-adherence. METHODS: A multicenter descriptive study was conducted involving 78 direct observations of provider-implemented protocols and 52 interviews with Peruvian maternal healthcare providers at 4 Peruvian clinical sites representing the local, regional, and national levels of care. Parturient participants planning a normal vaginal delivery were 17-49 years of age and 34-42 weeks pregnant. Primary outcomes were compared using χ2 testing, while quantitative survey data were evaluated using means, standard deviations, and Student t test or analysis of variance for statistical significance. RESULTS: There were 3 significant differences between the national, regional, and local levels of care: adherence to all 3 interventions (P<0.001); professional experience (P<0.04); and retention of healthcare providers (P<0.001). There were no differences in provider training (P<0.097), and the retention of experienced healthcare providers was not associated with greater adherence to protocols. There were no significant differences in parturient characteristics. CONCLUSION: Individual characteristics and institutional beliefs may have more influence than experience or training on adherence to protocols for prevention of postpartum hemorrhage; addressing these biases may improve patient safety in Peru and throughout Latin America.
Assuntos
Competência Clínica , Fidelidade a Diretrizes , Hemorragia Pós-Parto/prevenção & controle , Qualidade da Assistência à Saúde , Adolescente , Adulto , Atitude do Pessoal de Saúde , Centros Comunitários de Saúde/normas , Estudos Transversais , Feminino , Humanos , Capacitação em Serviço , Pessoa de Meia-Idade , Obstetrícia/educação , Cultura Organizacional , Segurança do Paciente , Reorganização de Recursos Humanos , Peru , Guias de Prática Clínica como Assunto , Gravidez , Centros de Cuidados de Saúde Secundários/normas , Centros de Atenção Terciária/normas , Adulto JovemRESUMO
OBJECTIVE: This is a repeat cohort study in which we sought to determine whether an association of necrotizing enterocolitis (NEC) <48 hours of a packed red blood cells (PRBC) transfusion was a prior sampling artifact. STUDY DESIGN: All very low birth weight neonates with NEC Stage ≥ IIB admitted over an 18-month period were categorized for NEC: (1) <48 hours after a PRBC transfusion; (2) unrelated to the timing of PRBCs; and (3) never transfused. RESULTS: Eight hundred eighty-three admissions over 18 months were reviewed; 256 were very low birth weight that resulted in 36 NEC cases and 25% were associated with PRBC (n = 9). PRBC-associated cases had lower birth weight, hematocrit, and rapid onset of signs (<5 hours). The timing of association of PRBC transfusion and NEC differed from random, showing a distribution that was not uniform over time (χ(2) = 170.7, df = 40; P < .000001) consistent with the possibility of a causative relationship in certain cases of NEC. Current weight at onset of NEC did not differ; however, the more immature the neonate the later the onset of NEC creating a curious centering of occurrence at a median of 31 weeks postconceptual age. CONCLUSIONS: We conclude that PRBC-related NEC exists. Transfusion-related acute gut injury is an acronym we propose to characterize a severe neonatal gastrointestinal reaction proximal to a transfusion of PRBCs for anemia. The convergence at 31 weeks postconceptual age approximates the age of presentation of other O(2) delivery and neovascularization syndromes, suggesting a link to a generalized systemic maturational mechanism.
Assuntos
Enterocolite Necrosante/etiologia , Transfusão de Eritrócitos/efeitos adversos , Recém-Nascido de muito Baixo Peso , Enterocolite Necrosante/epidemiologia , Feminino , Humanos , Recém-Nascido , Modelos Lineares , Masculino , New York/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
The contribution of mycorrhizal associations to maintaining tree diversity patterns in tropical rain forests is poorly known. Many tropical monodominant trees form ectomycorrhizal (EM) associations, and there is evidence that the EM mutualism contributes to the maintenance of monodominance. It is assumed that most other tropical tree species form arbuscular mycorrhizal (AM) associations, and while many mycorrhizal surveys have been done, the mycorrhizal status of numerous tropical tree taxa remains undocumented. In this study, we tested the assumption that most tropical trees form AM associations by sampling root vouchers from tree and liana species in monodominant Dicymbe corymbosa forest and an adjacent mixed rain forest in Guyana. Roots were assessed for the presence/ absence of AM and EM structures. Of the 142 species of trees and lianas surveyed, three tree species (the mono-dominant D. corymbosa, the grove-forming D. altsonii, and the non-dominant Aldina insignis) were EM, 137 were exclusively AM, and two were non-mycorrhizal. Both EM and AM structures wer e observed in D. corymbosa and D. altsonii. These results provide empirical data supporting the assumption that most tropical trees form AM associations for this region in the Guiana Shield and provide the first report of dual EM/AM colonization in Dicymbe species. Dual colonization of the Dicymbe species should be further explored to determine if this ability contributes to the establishment and maintenance of site dominance.