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1.  Demographics, clinical characteristics and neonatal outcomes in a rural Ugandan NICU 
Background
Ninety-six percent of the world’s 3 million neonatal deaths occur in developing countries where the majority of births occur outside of a facility. Community-based approaches to the identification and management of neonatal illness have reduced neonatal mortality over the last decade. To further expand life-saving services, improvements in access to quality facility-based neonatal care are required. Evaluation of rural neonatal intensive care unit referral centers provides opportunities to further understand determinants of neonatal mortality in developing countries. Our objective was to describe demographics, clinical characteristics and outcomes from a rural neonatal intensive care unit (NICU) in central Uganda from 2005–2008.
Methods
The NICU at Kiwoko hospital serves as a referral center for three rural districts of central Uganda. For this cross sectional study we utilized a NICU clinical database that included admission information, demographics, and variables related to hospital course and discharge. Descriptive statistics are reported for all neonates (<28 days old) admitted to the NICU between December 2005 and September 2008, disaggregated by place of birth. Percentages reported are among neonates for which data on that indicator were available.
Results
There were 809 neonates admitted during the study period, 68% (490/717) of whom were inborn. The most common admission diagnoses were infection (30%, 208/699), prematurity (30%, 206/699), respiratory distress (28%, 198/699) and asphyxia (22%, 154/699). Survival to discharge was 78% (578/745). Mortality was inversely proportional to birthweight and gestational age (P-value test for trend <0.01). This was true for both inborn and outborn infants (p < 0.01). Outborn infants were more likely to be preterm (44%, (86/192) vs. 33%, (130/400), P-value <0.01) and to be low birthweight (58%, (101/173) vs. 40%, (190/479), P-value <0.01) than inborn infants. Outborn neonates had almost twice the mortality (33%, 68/208) as inborn neonates (17%, 77/456) (P-value <0.01).
Conclusions
Understanding determinants of neonatal survival in facilities is important for targeting improvements in facility based neonatal care and increasing survival in low and middle income countries.
doi:10.1186/1471-2393-14-327
PMCID: PMC4174605  PMID: 25234069
Millennium development goals; Neonatal mortality; Sick newborn care; Infant mortality; Low-resource settings; Global health; Birthweight; Gestational age; Low and Middle Income Countries
2.  Enhancing Teamwork Between Chief Residents and Residency Program Directors: Description and Outcomes of an Experiential Workshop 
Background
An effective working relationship between chief residents and residency program directors is critical to a residency program's success. Despite the importance of this relationship, few studies have explored the characteristics of an effective program director-chief resident partnership or how to facilitate collaboration between the 2 roles, which collectively are important to program quality and resident satisfaction. We describe the development and impact of a novel workshop that paired program directors with their incoming chief residents to facilitate improved partnerships.
Methods
The Accreditation Council for Graduate Medical Education sponsored a full-day workshop for residency program directors and their incoming chief residents. Sessions focused on increased understanding of personality styles, using experiential learning, and open communication between chief residents and program directors, related to feedback and expectations of each other. Participants completed an anonymous survey immediately after the workshop and again 8 months later to assess its long-term impact.
Results
Participants found the workshop to be a valuable experience, with comments revealing common themes. Program directors and chief residents expect each other to act as a role model for the residents, be approachable and available, and to be transparent and fair in their decision-making processes; both groups wanted feedback on performance and clear expectations from each other for roles and responsibilities; and both groups identified the need to be innovative and supportive of changes in the program. Respondents to the follow-up survey reported that workshop participation improved their relationships with their co-chiefs and program directors.
Conclusion
Participation in this experiential workshop improved the working relationships between chief residents and program directors. The themes that were identified can be used to foster communication between incoming chief residents and residency directors and to develop a curriculum for chief resident development.
doi:10.4300/JGME-D-10-00226.1
PMCID: PMC3244337  PMID: 23205220
3.  Attitudes of Healthcare Providers towards Non-initiation and Withdrawal of Neonatal Resuscitation for Preterm Infants in Mongolia 
Antenatal parental counselling by healthcare providers is recommended to inform parents and assist with decision-making before the birth of a child with anticipated poor prognosis. In the setting of a low-income country, like Mongolia, attitudes of healthcare providers towards resuscitation of high-risk newborns are unknown. The purpose of this study was to examine the attitudes of healthcare providers regarding ethical decisions pertaining to non-initiation and withdrawal of neonatal resuscitation in Mongolia. A questionnaire on attitudes towards decision-making for non-initiation and withdrawal of neonatal resuscitation was administered to 113 healthcare providers attending neonatal resuscitation training courses in 2009 in Ulaanbaatar, the capital and the largest city of Mongolia where ~40% of deliveries in the country occur. The questionnaire was developed in English and translated into Mongolian and included multiple choices and free-text responses. Participation was voluntary, and anonymity of the participants was strictly maintained. In total, 113 sets of questionnaire were completed by Mongolian healthcare providers, including neonatologists, paediatricians, neonatal and obstetrical nurses, and midwives, with 100% response rate. Ninety-six percent of respondents were women, with 73% of participants from Ulaanbaatar and 27% (all midwives) from the countryside. The majority (96%) of healthcare providers stated they attempt pre-delivery counselling to discuss potential poor outcomes when mothers present with preterm labour. However, most (90%) healthcare providers stated they feel uncomfortable discussing not initiating or withdrawing neonatal resuscitation for a baby born alive with little chance of survival. Religious beliefs and concerns about long-term pain for the baby were the most common reasons for not initiating neonatal resuscitation or withdrawing care for a baby born too premature or with congenital birth-defects. Most Mongolian healthcare providers provide antenatal counselling to parents regarding neonatal resuscitation. Additional research is needed to determine if the above-said difficulty with counselling stems from deficiencies in communication training and whether these same counselling-related issues exist in other countries. Future educational efforts in teaching neonatal resuscitation in Mongolia should incorporate culturally-sensitive training on antenatal counselling.
PMCID: PMC3489950  PMID: 23082636
Antenatal counselling; Ethics; Low-income country; Neonates; Resuscitation; Mongolia
4.  Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions 
BMC Pregnancy and Childbirth  2010;10(Suppl 1):S3.
Introduction
Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).
Methods
Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.
Results
Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs:
• Two interventions prevent preterm births—smoking cessation and progesterone
• Eight interventions prevent stillbirths—balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery
• Eleven interventions improve survival of preterm newborns—prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome
Conclusion
The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.
doi:10.1186/1471-2393-10-S1-S3
PMCID: PMC2841444  PMID: 20233384
5.  Extended-interval Dosing of Gentamicin for Treatment of Neonatal Sepsis in Developed and Developing Countries 
Serious bacterial infections are the single most important cause of neonatal mortality in developing countries. Case-fatality rates for neonatal sepsis in developing countries are high, partly because of inadequate administration of necessary antibiotics. For the treatment of neonatal sepsis in resource-poor, high-mortality settings in developing countries where most neonatal deaths occur, simplified treatment regimens are needed. Recommended therapy for neonatal sepsis includes gentamicin, a parenteral aminoglycoside antibiotic, which has excellent activity against gram-negative bacteria, in combination with an antimicrobial with potent gram-positive activity. Traditionally, gentamicin has been administered 2–3 times daily. However, recent evidence suggests that extended-interval (i.e. ≥24 hours) dosing may be applicable to neonates. This review examines the available data from randomized and non-randomized studies of extended-interval dosing of gentamicin in neonates from both developed and developing countries. Available data on the use of gentamicin among neonates suggest that extended dosing intervals and higher doses (>4 mg/kg) confer a favourable pharmacokinetic profile, the potential for enhanced clinical efficacy and decreased toxicity at reduced cost. In conclusion, the following simplified weight-based dosing regimen for the treatment of serious neonatal infections in developing countries is recommended: 13.5 mg (absolute dose) every 24 hours for neonates of ≥2,500 g, 10 mg every 24 hours for neonates of 2,000–2,499 g, and 10 mg every 48 hours for neonates of <2,000 g.
PMCID: PMC2740664  PMID: 18686550
Developing countries; Drug therapy; Gentamicin; Infant, Newborn; Pharmacokinetics; Review literature; Sepsis

Results 1-5 (5)