Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews

Background Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. Objectives To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. Methods We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded. Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. Main results We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM. Effective Lifestyle versus usual care Lifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality). Promising No evidence for any outcome for any comparison could be classified to this category. Ineffective or possibly harmful Lifestyle versus usual care Lifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality). Exercise versus control Exercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality). Insulin versus oral therapy Insulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality). Probably ineffective or harmful interventions Insulin versus oral therapy For insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality). Inconclusive Lifestyle versus usual care The evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality). Exercise versus control The evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality). Insulin versus oral therapy The evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes. Insulin versus diet The evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality). Insulin versus insulin The evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality). No conclusions possible No conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low quality. Authors’ conclusions Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed

Clinical outcomes resulting from telemedicine interventions: a systematic review

BACKGROUND: The use of telemedicine is growing, but its efficacy for achieving comparable or improved clinical outcomes has not been established in many medical specialties. The objective of this systematic review was to evaluate the efficacy of telemedicine interventions for health outcomes in two classes of application: home-based and office/hospital-based. METHODS: Data sources for the study included deports of studies from the MEDLINE, EMBASE, CINAHL, and HealthSTAR databases; searching of bibliographies of review and other articles; and consultation of printed resources as well as investigators in the field. We included studies that were relevant to at least one of the two classes of telemedicine and addressed the assessment of efficacy for clinical outcomes with data of reported results. We excluded studies where the service did not historically require face-to-face encounters (e.g., radiology or pathology diagnosis). All included articles were abstracted and graded for quality and direction of the evidence. RESULTS: A total of 25 articles met inclusion criteria and were assessed. The strongest evidence for the efficacy of telemedicine in clinical outcomes comes from home-based telemedicine in the areas of chronic disease management, hypertension, and AIDS. The value of home glucose monitoring in diabetes mellitus is conflicting. There is also reasonable evidence that telemedicine is comparable to face-to-face care in emergency medicine and is beneficial in surgical and neonatal intensive care units as well as patient transfer in neurosurgery. CONCLUSIONS: Despite the widespread use of telemedicine in virtually all major areas of health care, evidence concerning the benefits of its use exists in only a small number of them. Further randomized controlled trials must be done to determine where its use is most effective

Informing the design of a trial of kangaroo mother care initiated before stabilisation amongst small and sick newborns in a sub-Saharan African context using mixed methods

An estimated 2.5 million neonates die every year, with preterm birth being the leading cause. Sub-Saharan Africa and southern Asia account for 78% of neonatal deaths. The WHO recommends kangaroo mother care (KMC) for stabilised newborns ≤2000g; however, most deaths occur before stabilisation. An evidence gap exists regarding KMC for this population. The overall aim of this PhD was to inform the design of a trial of KMC initiated before stabilisation in a sub-Saharan African context. The first part focused on assessing facility readiness and quantifying neonatal mortality risk. Cascade models were developed and used to assess 23 East African facilities. A logistic model was derived and validated using data from 187 UK hospitals and one Gambian hospital. The final model, including three parameters, demonstrated very good performance. The score requires further validation in low-resource contexts, but has potential to improve neonatal resource allocation. The second part of this PhD focused on evaluating the feasibility of initiating KMC before stabilisation and designing the trial. This study showed it was feasible to monitor and provide care in the KMC position, and found the intervention was acceptable to parents and providers. Launched in 2020, the OMWaNA trial will determine the mortality impact of this intervention within 7 days relative to standard care at four Ugandan hospitals. Process and economic evaluations will explore causal pathways for clinical effects, estimate incremental cost and costeffectiveness, and examine barriers and facilitators to inform uptake and sustainability. This PhD has developed a cascade model to assess facility readiness, validated a score to assess individual risk, and demonstrated the feasibility of initiating KMC before stabilisation. These studies have informed the design of a trial evaluating the mortality impact of this intervention in Uganda. The findings are expected to have broad applicability to low-resource hospitals and important policy implications

The Impact of Patient Characteristics on Dysphagia Therapy Utilization and Feeding Outcomes for Premature Infants in the Neonatal Intensive Care Unit

Medical advances have significantly increased the survival rates of preterm infants at lower gestational ages. However, infants born at lower gestational ages have an increased risk for developmental disabilities and oral feeding difficulties. A stay in the neonatal intensive care unit (NICU) is very costly and inadequate oral feeding is the most common barrier to discharge for premature infants. Infants can receive dysphagia therapy services during their NICU stay that focuses on the development of oral feeding and swallowing skills. However, literature to this date has mainly focused on the impact of therapy services for premature infants after NICU discharge. The purpose of this dissertation is to describe the scope of dysphagia therapy for preterm infants in a Level IV NICU and to determine the association between infant characteristics, dysphagia therapy utilization, and feeding outcomes. This study uses a correlational retrospective study design to analyze secondary data extracted from the electronic medical record for all eligible infants who were born at less than 37 weeks of gestation, with a history of admission to a Level IV NICU between January 2017 and December 2019. Variables for this study were selected using Gelberg’s Behavioral Model for Vulnerable Populations by examining how preterm infant characteristics impact dysphagia therapy service utilization, which ultimately impact their feeding outcomes. The results showed that mainly need factors, such as gestational age, birthweight, and medical complexity, were associated with receipt of dysphagia therapy referral, referral type, number of treatment sessions, and postmenstrual age (PMA) at independent oral feeding. Regression analysis showed that when controlling for infant characteristics, the receipt of dysphagia therapy was associated with higher PMA at independent oral feeding. This is likely due to infants who received dysphagia therapy referrals having higher medical complexities. Findings from this study contributes to understanding of the provision of dysphagia therapy, which could lead to earlier identification of populations that are at higher risk for delayed achievement of independent oral feeding and the creation of protocols for the referral process for those infants. More research is needed to further understand and address factors that impact neonatal feeding outcomes and length of stay to ultimately decrease healthcare costs

Mobile applications for prematurity:A systematic review protocol

Background Premature birth is a global epidemic of significant public health concern. Counselling and education of pregnant women at risk of preterm birth or mothers with premature infants are essential to improve mother and infant health. Mobile applications are an increasingly popular tool among parents to receive health information and education. This study aims to evaluate the usages and the effects of a mobile application designed for premature births in order to improve health outcomes. Methods This review will include all studies of different designs which evaluated the use and impact of interventions provided via mobile applications on pregnant women at risk of preterm birth or mothers with premature infants in order to address all health outcomes. A combination of keywords and MeSH(Medical Subject Headings) terms is used in the search strategy. Literature databases including Scopus, PubMed, ISI Web of Science, ProQuest, CINAHL and Cochrane Library will be searched to May 2021. Furthermore, eligible studies will be chosen from the reference list of retrieved papers. Two researchers will independently review the retrieved citations to decide whether they meet the inclusion criteria. Mixed Methods Appraisal Tool (MMAT) V.2018 will be used to assess the quality of studies. Relevant data are collected in a data extraction form and analysed. Results are reported under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Discussion This systematic review will recognize and combine evidence about the usages and impact of mobile application interventions on the health improvement of pregnant women at risk of preterm birth or mothers with premature infants

Facilitators and Barriers to Neonatal Intensive Care Unit Follow-Up Program Attendance: A Critically Appraised Topic

Kari Tanta, PhD, OTR/L, FAOTA is the rehabilitation manager of the neonatal intensive care unit (NICU) and the NICU follow-up (NFU) program at Valley Medical Center (VMC). To address the problem of decreased NFU attendance, the following clinical question was asked: “For families with an infant who has been discharged from a NICU, which factors promote or discourage utilization of follow-up services?” Numerous facilitators and barriers affecting attendance were identified relating to severity of infant illness, parent socioeconomic status and education levels, and pragmatic factors including timing of scheduling. Knowledge translation activities undertaken included collaboration with University of Washington (UW) students, collaboration with grant writer Leanna Birge, PhD, and submission of findings for publication. Due to conflicting schedules, collaboration with the UW students was limited to a brief telephone dialogue. The collaboration with Dr. Birge will directly support the acquisition of grants for informal quality improvement (QI) studies. The submitted article will potentially reach many readers specializing in pediatrics, though it is difficult to assess the true reach of the article. Further research should investigate effective methods for increasing NFU program service utilization

Family Centered Care in the Neonatal Intensive Care Unit: A Standard Checklist for Nurses and Parents

Neonatal Intensive Care Units (NICUs) care for critically ill newborn babies. Family Centered Care (FCC) is a relatively new standard of NICU care that allows for caregivers to be as much of a part of the NICU experience as health care providers. This thesis utilized a review of literature to identify research that shows that FCC is an effective way to improve outcomes for neonates and their caregivers. Many sources did provide evidence for this. Some evidence shows that FCC can lead to shorter length of stay, increased rates of breastfeeding, and increased weight gain for the neonates, while parents/caregivers see increased bonding and parent-infant attachment and decreased stress and anxiety. An additional review of literature identified specific evidence-based interventions that work with FCC. However, there is no standardized way for NICU staff (namely nurses) to implement all of these aspects of FCC that are shown to be conducive to improved outcomes. For this thesis, a standard checklist, composed of evidence-based FCC interventions (including communication, parent education, empowerment, basic infant care, breastfeeding, private rooms, bonding, and technology), was created to streamline the process of FCC in the NICU. The utilization of this checklist will help nurses and parents to ensure their neonate is benefitting from their care