Chyi Her Lin

Systematic review of effectiveness of situated e-learning on medical and nursing education.

OBJECTIVESnBecause of the complexity of clinical situations, traditional didactic education is limited in providing opportunity for student-patient interaction. Situated e-learning can enhance learners knowledge and associated abilities through a variety of activities. Healthcare providers who interact with virtual patients in designed situations may avoid unnecessary risks and encounters with real patients. However, the effectiveness of situated e-learning is inconsistent. The purpose of this study is to determine the effectiveness of situated e-learning in prelicensure and postlicensure medical and nursing education.nnnMETHODSnLiterature databases of PubMed, Medline, CINAHL, ERIC, and Cochrane Library were searched. The study eligibility criteria included articles published in English, which examined the effectiveness of situated e-learning on the outcomes of knowledge and performance for clinicians or students in medicine and nursing. Effect sizes were calculated with 95% confidence intervals.nnnRESULTSnFourteen articles were included for meta-analysis. Situated e-learning could effectively enhance learners knowledge and performance when the control group received no training. Compared to traditional learning, the effectiveness of situated e-learning on performance diminished but still remained significant whereas the effect become insignificant on knowledge. The subgroup analyses indicate the situated e-learning program significantly improved students clinical performance but not for clinicians.nnnCONCLUSIONSnSituated e-learning is an effective method to improve novice learners performance. The effect of situated e-learning on the improvement of cognitive ability is limited when compared to traditional learning. Situated e-learning is a useful adjunct to traditional learning for medical and nursing students.

Noise and Related Events in a Neonatal Intensive Care Unit

The purposes of this study were to explore noise distribution, its timing, and sources of peak noise in the neonatal intensive care unit (NICU) of a University Hospital in Southern Taiwan. Two surveys on noise distribution and peak noise of the warmer bed were conducted. Noise at radiate heated beds located in the central sites of two areas, one near (Area A) and the other away from (Area B) the nursing station, were measured continuously for one week using an electronic sound-meter. Peak noise with a sound level of > 65 on the A-weighted decibel scale (dBA) and associated sources were recorded for 48 hours. Monitoring periods of peak noise consisted of a weekday and a day on the weekend randomly selected for Area A. Results showed that mean noise levels at the warmer bed in Areas A and B were 62 and 61.4 dBA on average. In over 70% of the total observation time for both areas the sound levels were > 59 dBA. The noise intensity was particularly high between 8 a.m. and 4 p.m. The noise level on the weekend was lower than that on weekdays. During the 48-hour observation period, 4994 peak noises were recorded. Eighty-six percent of these peak noises were within ranges of 65-74 dBA and 90% were human-related factors. The primary non-human related source was monitor alarms. Additionally, peak noises occurred primarily during the 8-11 a.m. and 2-4 p.m. hours on the weekdays and weekends. These results indicate that modifications of staff behavior, care procedures, and apparatus may reduce the noise levels in the NICU.

effects of Single-hole and Cross-cut Nipple Units on Feeding Efficiency and Physiological Parameters in Premature Infants

&NA; The purpose of this study was to compare the amount of total milk intake, feeding time, sucking efficiency, heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2) of premature infants when fed with either signal-hole or cross-cut nipple units. Twenty stable infants admitted to a level II nursery in a tertiary care center with gestational ages averaging 32.2 ± 3.2 wks were enrolled. Subjects had an average postmenstrual age of 34.1 ± 1.6 wks, and average body weight of 1996 ± 112 gm. A crossover design was used and infants were observed for two consecutive meals separated by a four-hour interval. They were bottle fed with equal feeding amounts using a single-hole and cross-cut nipple administered in random order. Results showed that infants fed with single-hole nipple units took more milk (57.5 ± 8.3 ml vs. 51.6 ± 9.5 ml, p = .011), had a shorter feeding time per meal (11.5 ± 4.9 min vs. 20.9 ± 5.0 min, p <.001), and sucked more efficiently (5.8 ± 2.5 ml/min vs. 2.7 ± 1.0 ml/min, p < .001) compared to those fed through cross-cut nipples. Infants using cross-cut nipple units had a higher RR (44.4 ± 4.6 breaths/minutes vs. 40.8 ± 4.9 breaths/minutes, p = .002) and SpO2 (96.1 ± 1.4% vs. 94.6 ± 3.2%, p = .044) than those using single-hole nipples. Oxygen desaturation (SpO2 < 90% and lasting for longer than 20 sec) and bradycardia were not recorded in either group of infants during feeding. Compared to using cross-cut nipple units, premature infants using single-hole nipple units take more milk and tend to tolerate feedings better. A single-hole nipple may be a choice for physiologically stable bottle-fed premature infants.

Neonatal Outcomes of Extremely Preterm Infants from Taiwan: Comparison with Canada, Japan, and the USA

BACKGROUNDnThis study compared the current trend in survival rates and morbidity for very low birth weight (VLBW) infants in five Medical Training Centers of Prematurity for the Premature Baby Foundation of Taiwan (PBFT), with the outcomes from the USA, National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN), the Canadian Neonatal Network (CNN), and the Neonatal Research Network of Japan (NRNJ).nnnMETHODSnThe survival rates of VLBW infants according to gestational age (GA) and major morbidities were compared between networks (Taiwan, USA, Canada, and Japan). Taiwanese data for VLBW infants of GA ≤28 weeks between 2007 and 2012 were obtained from the PBFT Annual Conferences of Premature Care reports defining survival rate as neonates that survived to the time of discharge. Major morbidities included severe neurological injury (Grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia), bronchopulmonary dysplasia, severe retinopathy of prematurity, necrotizing enterocolitis, late-onset sepsis, and patent ductus arteriosus.nnnRESULTSnThe survival rates of VLBW infants of GA ≤28 weeks from the PBFT (Taiwan), NICHD NRN (USA), CNN (Canada), and NRNJ (Japan) were 77% (1323/1718), 72% (6859/9575), 82% (2353/2872), and 89% (4489/5069), respectively. The annual survival rates in Taiwan from 2007 to 2012 were 72%, 76%, 76%, 74%, 77%, and 78%, respectively. When GA from ≤23 weeks to 28 weeks was assessed in Taiwan, the survival rates of VLBW infants according to each week were 22%, 50%, 70%, 80%, 88%, and 92%, respectively. The survival rate, especially at lower GAs, was highest in the NRNJ (Japan). The major difference between Taiwan and Japan was attributed to the lower survival rates at lower GA (≤26 weeks) in Taiwan. Japan had the lowest rates of major morbidities among the four countries.nnnCONCLUSIONnThe survival rate of VLBW infants has improved over the past 6 years in Taiwan. It is higher than the USA, but lower than Canada and Japan. However, the results from Taiwan are from five Medical Training Centers for the PBFT rather than from a population-based study. It is crucial to have a nationwide neonatal research network to develop new practical approaches for VLBW infants in Taiwan.

Eosinophilia in very low birth weight infants.

BACKGROUNDnEosinophilia is common in premature infants, though its clinical significance remains unknown. This study investigated the pattern of eosinophilia and related factors in very low birth-weight (VLBW) infants.nnnMETHODSnThe medical records of VLBW infants (birth body weight < 1500 g) admitted to the neonatal intensive care unit of a tertiary care center of Cheng Kung University Hospital between January 2005 and June 2007 were analyzed. Complete blood counts (CBC) with differential leukocyte counts were performed weekly. Eosinophilia was defined as an eosinophil count of more than 0.700 x 10(9)/L. The possible related factors were analyzed.nnnRESULTSnA total of 142 infants were recruited into the study. Those who did not survive after the first 28 days and those with less than four available CBCs were excluded, leaving 107 infants and 828 CBC measurements. Overall, 19.0% of CBCs (157/828) indicated eosinophilia and 69.0% of all infants had at least one instance of eosinophilia during their hospital stay. Eosinophilia mainly occurred in the third week of life (27.1%), with an average peak eosinophil count of 0.520 x 10(9)/L. There were 37.3% of patients with mild eosinophilia (0.700-0.999 x 10(9)/L), 50.7% with moderate eosinophilia (1.000-2.999 x 10(9)/L), and 12% with severe eosinophilia (> or =3.000 x 10(9)/L). The demographic data and perinatal characteristics of infants with and without eosinophilia were comparable. Medical treatments including mechanical ventilation, antibiotic administration, total parenteral nutrition, intravenous catheterization, transfusion, and body weight gains were similar between the two groups. The eosinophil counts in the first week of life were significantly higher in infants with bronchopulmonary dysplasia (p < 0.05). They were also greater in VLBW infants with sepsis at the first, the third, the fourth, the fifth and the seventh weeks (p < 0.05).nnnCONCLUSIONnEosinophilia is common in VLBW infants and occurs mainly in the third week of life. Higher eosinophil counts were associated with sepsis and family history of atopic eczema. Bronchopulmonary dysplasia was associated with higher eosinophil counts in the first week of life.

Growth and Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants: A Single Center's Experience

BACKGROUND/PURPOSEnThe outcome of extremely low birth weight (ELBW, ≤1000 g) infants has recently been improved in Taiwan. However, their postdischarge anthropometry and development have seldom been explored. We report these results for ELBW infants at corrected age of 2 years in a tertiary care center.nnnMETHODSnThis descriptive and retrospective study enrolled ELBW infants discharged alive from a tertiary care center from January 2004 to December 2007. A scheduled follow-up program up to 2-year corrected age was tightly controlled by a case manager. Bayley Scales of Infant Development-Second Edition, representing the mean ± 1 standard deviation as 100 ± 15 in normal population, was used to assess infants development. An index less than 70 was regarded as abnormal. Anthropometry, including body weight (BW), body length (BL), and head circumference (HC), against the growth standard from the World Health Organization was assessed. Growth delay was defined as growth parameters below the 10(th) percentile values.nnnRESULTSnOne hundred ELBW infants were enrolled. Eighty of them were discharged alive (80% surviving), and their follow-up rates were 91% at 6 months, 90% at 12 months, and 83% at 24 months corrected ages. The 2-year survival rate was 75%. The percentages of delayed growth in BW/BL/HC, presented as (male vs. female), were (33/41/37 vs. 38/25/45) at 6 months, (31/31/50 vs. 41/22/37) at 12 months, and (39/36/54 vs. 26/29/38) at 24 months. The negative means of the Z score for BW/BL/HC in both genders indicated ELBW infants had significant growth delay compared with those of the normal population. The index of Bayley scales was significantly lower in ELBW infants than that in normal population at each age. Male infants had lower mental development index and psychomotor development index at 2 years than females. About 61% of those with BW less than 750 g died or had neurodevelopmental impairment.nnnCONCLUSIONnELBW infants have a high incidence of growth and developmental delay at corrected age of 2 years, particularly in male infants or those with BW less than 750 g. This study reveals that ELBW infants require well predischarge planning and postdischarge follow-up.

Feeding with cross-cut teats has better sucking effects and oxygenation in preterm infants with chronic lung disease

AIMnTo compare effects of single-hole and cross-cut teats on feeding performance, oral movement and cardiorespiratory parameters in preterm infants with chronic lung disease.nnnBACKGROUNDnInfants feeding performance and physiological stability are affected by the shape and hole size of teats because of varied milk flow. The single-hole teat could facilitate efficient milk intake in healthy preterm infants. In preterm infants with chronic lung disease, few studies have determined which type of teat is suitable for feeding.nnnDESIGNnA crossover study design was conducted.nnnMETHODSnTwenty preterm infants with chronic lung disease were studied in a neonatal intensive care unit. During the early stage in transitional period of oral feeding, each infant was provided with a small single-hole, an intermediate single-hole and a cross-cut teat with diameters of 0.45-0.5 mm, 0.7-0.8 mm and 2.0 mm, respectively, for three consecutive feeds in a random order. Feeding performance, oral movement, heart rate, respiratory rate and oxygen saturation (SpO(2)) were measured.nnnRESULTSnInfants fed with single-hole teats had a shorter duration of feeding time (p < 0.001) and higher feeding efficiency (p < 0.001) compared with the cross-cut teats. However, infants fed with cross-cut teats had a higher sucking pressure (p < 0.001), more sucks (p < 0.001) and bursts (p < 0.001), longer sucking duration (p = 0.002) and higher respiratory rate (p = 0.005) and SpO(2) (p = 0.014) than infants fed with single-hole teats.nnnCONCLUSIONSnFor preterm infants with chronic lung disease, cross-cut teats facilitate feeding coordination and physiological stability during the early stage of the transition from tube to oral feeding.nnnRELEVANCE TO CLINICAL PRACTICEnCross-cut teat can be considered for preterm infants with chronic lung disease to increase safety and self-regulation in the early stage of the transition from tube to oral feeding.

Family-centered care improved neonatal medical and neurobehavioral outcomes in preterm infants: Randomized controlled trial

Background Family‐centered care for preterm infants in Western societies has yielded short‐ to medium‐term benefits. However, the intervention effects have rarely been validated in Eastern societies. Objective The aim of this study was to examine whether a family‐centered intervention program (FCIP) could improve the short‐term medical and neurobehavioral outcomes in preterm infants with very low birth weight (VLBW; a birth weight of <1,500 g) in Taiwan over the outcomes seen with a usual care program (UCP). Design This was a multicenter, single‐blind, randomized controlled trial study. Setting Three medical centers in northern and southern Taiwan were the locations for the study. Participants The participants were 251 VLBW preterm infants without severe perinatal complications. Intervention The infants were randomly assigned to receive the FCIP or the UCP during hospitalization. Measurements Infant morbidities, feeding, growth, and neurobehavioral performance were evaluated during the neonatal period. Parental adherence to interventions was measured in the FCIP group. Results The FCIP promoted earlier full enteral feeding (&bgr; = ‐1.1 weeks; 95% CI = ‐1.9 to ‐0.2 weeks) and hospital discharge (&bgr; = ‐0.6 week; 95% CI = ‐1.1 to ‐0.1 weeks), greater weight gain (&bgr; = 3.3 g/d; 95% CI = 0.1 to 6.6 g/d), and better neurobehavioral performance than the UCP (&bgr; = 1.2 points; 95% CI = 0.2 to 2.3 points). Furthermore, a higher degree of parental motivation in interventions, goal attainment, and comprehensiveness of home activities was significantly associated with greater effects in infants’ neurobehavioral performance and weight gain (r = .20‐.31; all Ps < .05). Limitations The findings may not be generalized to preterm infants with severe perinatal diseases and parents with a low level of interest in interventions. Conclusions Family‐centered care facilitated short‐term medical and neurobehavioral outcomes in VLBW preterm infants in Taiwan; the effects were likely achieved through parental adherence to interventions. The designated strategies may be considered in a future launch of family‐centered care in Taiwan.

Therapeutic Hypothermia for Neonates with Hypoxic Ischemic Encephalopathy

Therapeutic hypothermia (TH) is a recommended regimen for newborn infants who are at or near term with evolving moderate-to-severe hypoxic ischemic encephalopathy (HIE). The Task Force of the Taiwan Child Neurology Society and the Taiwan Society of Neonatology held a joint meeting in 2015 to establish recommendations for using TH on newborn patients with HIE. Based on current evidence and experts experiences, this review article summarizes the key points and recommendations regarding TH for newborns with HIE, including: (1) selection criteria for TH; (2) choices of method and equipment for TH; (3) TH prior to and during transport; (4) methods for temperature maintenance, monitoring, and rewarming; (5) systemic care of patients during TH, including the care of respiratory and cardiovascular systems, management of fluids, electrolytes, and nutrition, as well as sedation and drug metabolism; (6) monitoring and management of seizures; (7) neuroimaging, prognostic factors, and outcomes; and (8) adjuvant therapy for TH.

Transcutaneous bilirubin nomogram for Taiwanese newborns – A single center study

BACKGROUNDnHour-specific bilirubin nomogram has been recommended to predict postdischarge hyperbilirubinemia in newborns. However, it may not be applicable in Taiwan due to ethnic differences. The aim of this study was to construct a 12-h specific transcutaneous bilirubin (TCB) nomogram in newborns for clinical reference.nnnMETHODSnWe prospectively enrolled full term or late preterm neonates born in a tertiary care hospital between October 2013 and July 2014. The exclusion criteria included chromosome anomaly, glucose-6-phosphate dehydrogenase deficiency, and receiving phototherapy within 60xa0h after birth. TCB measurements were performed by a single technician using the Bilichek device, and measured every 12xa0h until neonates were discharged. Patient data including sex, delivery mode, gestational age, body weight with daily change, and feeding pattern were collected for analysis. A TCB nomogram was constructed with 40th, 75th, and 95th percentile lines.nnnRESULTSnA total of 498 newborns were enrolled, and the characteristics between the hyperbilirubinemia and nonhyperbilirubinemia groups were not different. The mean TCB curve revealed that the peak TCB level was 14.2xa0±xa02.9xa0mg/dL at 100.6xa0±xa03.6xa0h of age. The peak 95th percentile TCB level was 19.4xa0mg/dL at 121.9xa0±xa05xa0h of age. Mean TCB levels increased at a rate of 0.01-0.21xa0mg/dL/h initially, followed by a decrease after 96-108xa0h of age. Twenty newborns (4%) were diagnosed with hyperbilirubinemia. Regarding TCB distribution, 11 of 60 (18%) had peak TCB levels above the 95th percentile, 5 of 151 (3%) had TCB levels between the 75th and 95th percentile, 4 of 200 (2%) had levels between the 40th and 75th percentiles, and none had a level below the 40th percentile.nnnCONCLUSIONnA 12-h specific TCB nomogram could be a useful reference for workup for hyperbilirubinemia, particularly when it is above the 95th percentile line.