Usage of EMBRACE TM in Gujarat, India: Survey of Paediatricians

Aim. EMBRACE TM is an innovative, low cost infant warmer for use in neonates. It contains phase change material, which stays at constant temperature for 6 hours. We surveyed paediatricians using EMBRACE TM regarding benefits, risks, and setup in which it was used in Gujarat. Methods. Questionnaire was administered telephonically to 52 out of 53 paediatricians. Results. EMBRACE TM was used for an average of 8.27 (range of 3-18, SD = 3.84) months by paediatricians. All used it for thermoregulation during transfers, for average (SD) duration of 42 (0.64) m per transfer, 62.7% used it at mother's side for average (SD) 11.06 (7.89) h per day, and 3.9% prescribed it at home. It was used in low birth weight neonates only by 56.9% while 43.1% used it for all neonates. While hyperthermia was not reported, 5.9% felt that EMBRACE TM did not prevent hypothermia. About 54.9% felt that they could not monitor the newborn during EMBRACE TM use. Of paediatricians who practiced kangaroo mother care (KMC), 7.7% have limited/stopped/decreased the practice of KMC and substituted it with EMBRACE TM . Conclusions. EMBRACE TM was acceptable to most but concerns related to monitoring neonates and disinfection remained. Most paediatricians felt that it did not hamper KMC practice

Can Physician Champions Improve Kangaroo Care? Trends over 5 Years in Rural Western India

Introduction: In 2013, approximately 2.8 million children worldwide died within the neonatal period. India is at the epicenter of this tragedy, accounting for one-third of all neonatal mortalities. Prematurity and/or with low birth weight are the leading cause of neonatal mortality and India has the highest number of neonates born preterm and weighing less than 2,500 grams worldwide. It is estimated that Kangaroo Care can avert up to 48% of all neonatal deaths among premature babies by 2025. However, the promise of Kangaroo Care as a low-cost, safe, and efficacious intervention to reduce neonatal mortality in India has not been realized due to suboptimal implementation. Physician champions can improve Kangaroo Care implementation, but the magnitude of their impact is unknown. Methods: A retrospective cohort study of 648 infants identified using clinical data from a NICU located in rural western India. Physicians who led Kangaroo Care training sessions with neonates and coached peer healthcare professionals were considered champions. Two Kangaroo Care champions were on staff full-time from January 2010 through June 2011, part-time from July 2011 through June 2012, and absent thereafter. We examined the effect of the withdrawal of physician champions on overall use using logistic regression, time to initiation using competing risk cox regression, and intensity using linear regression models of the two main components of Kangaroo Care, skin-to-skin care and breastfeeding, separately. Findings: In comparison to when Kangaroo Care champions were present, their absence was associated with a 45% decrease in the odds of receiving skin-to-skin care (95% CI): 64% to 17%), 38% decrease in the rate of initiation of skin-to-skin care (95% CI: 53% to 82%), and on average, 1.47 less hours of skin-to-skin care (95% CI: -2.07 to -0.86). Breastfeeding practices were similar across different champion environments. Interpretation: Withdrawal of Kangaroo Care champions from neonatal intensive care unit in rural western India is associated with diminished administration, delayed initiation, and shorter duration of skin-to-skin care, but did not impact breastfeeding practices. Training healthcare workers and community stakeholders to become champions could help in scaling up and maintaining Kangaroo Care practices. Funding: This research was supported by TL1-TR001454 (to A.S.) from National Center for Advancing Translational Sciences, and P60-MD006912-05 (to J.A.) from National Institute on Minority Health and Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH

An improved proportionate delayless multiband-structured subband adaptive feedback canceller for digital hearing aids

Acoustic feedback cancellation is one of the challenging tasks in the design of a behind the ear (BTE) digital hearing aid. This feedback cancellation is usually achieved using an adaptive filter. The finite correlation between the desired microphone input signal and the input signal to the loudspeaker results in a biased estimation of the adaptive filter, which may produce disturbances in the hearing aid. Prediction error method (PEM) has been used in literature to reduce the bias effects. The convergence of a PEM based feedback canceller can be improved by implementing the adaptive filter in the subband domain. However, a direct subband implementation results in aliasing issues, band-edge problems and introduces a delay due to analysis and synthesis filters. In order to reduce the aliasing and delay issues, a delayless subband implementation of a PEM based feedback canceller is designed in this paper. A delayless multiband-structured subband implementation of the feedback canceller is also attempted to further reduce the aliasing and band-edge effects. This implementation aims at having all the subbands collectively updating the fullband adaptive filter, without the need for a subband to fullband weight conversion and offers improved feedback cancellation at reduced computational load in comparison with a delayless subband implementation of a PEM based feedback canceller. In addition, an attempt has been made to further improve the convergence behaviour by using an improved proportionate learning scheme. The improved convergence offered by the proposed scheme is evident from the simulation study. The improvement has been further quantified using a perceptual evaluation of speech quality and the proposed approach has been shown to provide enhanced speech quality.by Somanath Pradhan, Vinal Patel, Dipen Somani and Nithin V. Georg

Ureter-iliac artery graft-cutaneous fistula: A rare presentation

A 55-year-old male with a history of iliac artery – popliteal artery polytetrafluoroethylene graft bypass presented 2 years later with sudden onset gross hematuria with sepsis. Computed tomography (CT) angiography was suggestive of fistula between ureter and iliac artery which was treated with arterial covered stent graft. The patient presented 2 weeks later with watery discharge from the previous scar. CT suggested ureter-cutaneous fistula. JJ stenting of ureter was done. The patient was discharged and on follow-up CT scan, there was no evidence of fistula and patient was completely asymptomatic. Ureter-iliac artery graft fistula with cutaneous involvement has not been reported in literature before

A time–motion analysis of the mothers staying in the neonatal care unit

Context: In addition to various barriers studied for kangaroo mother care (KMC), time opportunities for better implementation of KMC need to be studied. Aim: Time–motion analysis of the mother's daily activities was carried out to identify scope to improve KMC. Settings and Design: This is a 24-h recall-based questionnaire study. Mothers were interviewed whose newborns were admitted at a tertiary and secondary care neonatal care unit of western India over a period of 9 months from November 2015 to July 2016. Materials and Methods: Mothers were approached when the preterm neonate and mother dyad was eligible for KMC, that is, when mothers were physically healthy and newborns were physiologically stable. A total of 60 mothers were enrolled in the study. Mothers' daily activities were noted, and time spent in each activity was charted for 3 consecutive days. Missed time opportunities which could be used to increase daily KMC hours were studied. Statistical Analysis Used: To compare quantitative variables, two-sample unpaired t-test and one-way analysis of variance were used. Results: The average time of activities which consumed most was 8.24 h for sleep/rest, 3.46 h for meals/snacks, 4.89 h for breastfeeding, and a daily average of only 1.4 h was used for KMC. A quite a significant proportion, that is, 3.89 h, was spent for meeting relatives which could be used for KMC as well without affecting social meetings. Conclusion: Time–motion analysis was helpful to find out weak links in KMC implementation. Providing family-centered environment in terms of implementing KMC during meeting hours with family may augment KMC hours

Practices of Procedural Pain Management in Neonates through Continuous Quality Improvement Measures

Objective. Although the benefits of pain control measures in neonates are well known, the actual usage was not optimal in our unit. Therefore, we implemented a quality improvement project to improve pain management practices through multiple Plan-Do-Study-Act (PDSA) cycles. Method. Our project included hemodynamically stable newborns weighing ≥1300 g. We identified four common procedures: intravenous cannulation, venous sampling, heel prick, and nasogastric tube insertion. The selected pain control measures were skin-to-skin contact, breastfeeding, expressed breast milk orally, and oral sucrose. Between April 2019 and September 2019, we intervened multiple times and reassessed shortcomings. We encouraged evidence-based practices and gave solutions for shortcomings. Data were interpreted weekly to assess the compliance to pain control interventions. Results. Minimal pain control measures (3-4%) were utilized for identified procedures before the project began. We could improve the use of pain control measures steadily and achieve the target of 80% of procedures after seven different interventions over five months. There was a retention of the effect on reassessing twice at second and fourth months of stopping further intervention once the target got achieved. Conclusion. Quality Improvement science can identify the shortcomings and help to improve the compliance for pain control practices in neonates, as demonstrated in this neonatal unit

Breastfeeding Practices, Demographic Variables, and Their Association with Morbidities in Children

Appropriate feeding practices are the key contributor to reducing morbidities and mortalities in under-five children. A cross-sectional questionnaire based survey of mothers of children aged less than 5years was conducted in 781 mothers. More than half of mothers (57.5%) started feeding within an hour of birth, 55.9% gave exclusive breastfeeding for six months, 89.1% of the mothers stopped breastfeeding before two years of age, 18.2% of the mothers bottle-fed the babies, and 15.6% had problems during breastfeeding in first 6 months. Early initiation of breastfeeding within one hour of birth promoted exclusive breastfeeding, and breastfeeding for longer duration. Exclusive breastfeeding increased frequency of feeds. Multivariable logistic regression showed that initiation of breastfeeding after an hour of birth (p = 0.035), not providing exclusive breastfeeding for 6 months (p < 0.0001), unemployed mothers (p = 0.035), having two or more kids (p = 0.001), and complementary feeds given by person other than mother (p = 0.007) increased hospitalization. Starting breastfeeding after an hour of birth (p = 0.045), severe malnutrition (p = 0.018), and breastfeeding for < two years (p = 0.026) increased rates of diarrhea. Breastfeeding practices were not optimum and interventions to improve these practices need to be strengthened

Current Neonatal Resuscitation Practices among Paediatricians in Gujarat, India

Aim. We assessed neonatal resuscitation practices among paediatricians in Gujarat. Methods. Cross-sectional survey of 23 questions based on guidelines of Neonatal Resuscitation Program (NRP) and Navjaat Shishu Suraksha Karyakram (NSSK) was conducted using web-based tool. Questionnaire was developed and consensually validated by three neonatologists. Results. Total of 142 (21.2%) of 669 paediatricians of Gujarat, India, whose e-mail addresses were available, attempted the survey and, from them, 126 were eligible. Of these, 74 (58.7%) were trained in neonatal resuscitation. Neonatal Intensive Care Unit with mechanical ventilation facilities was available for 54% of respondents. Eighty-eight (69.8%) reported correct knowledge and practice regarding effective bag and mask ventilation (BMV) and chest compressions. Knowledge and practice about continuous positive airway pressure use in delivery room were reported in 18.3% and 30.2% reported use of room air for BMV during resuscitation. Suctioning oral cavity before delivery in meconium stained liquor was reported by 27.8% and 38.1% cut the cord after a minute of birth. Paediatricians with NRP training used appropriate method of tracheal suction in cases of nonvigorous newborns than those who were not trained. Conclusions. Contemporary knowledge about neonatal resuscitative practices in paediatricians is lacking and requires improvement. Web-based tools provided low response in this survey