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Thesis (MPhil)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: This thesis discusses the value of medical futility as an action guide for neonatal endof- life decisions. The concept is contextualized within the narrative of medical progress, the uncertainty of medical prognostication and the difficulty of just resource allocation, within the unique African situation where children are worse off today than they were at the beginning of the last century. parties actively engage in an interactive deliberation for a plan of action. Both parties ought to accept moral responsibility. Such a model of deliberation has the added advantage of transcending the limitations of the participants to arrive at a higher-level solution, which is considered more than just a consensus. It has been argued that medical progress has obscured the basic need for human compassion for the dying and for their loved ones. The literature furthermore reports that the quality of end-of-life care is unsatisfactory for both patients and their families. It is within this context that the concept of medical futility is positioned as a useful action guide. As we do not have the luxury of withdrawing from the responsibility to engage in the deliberation of end-of-life decisions, such responsibility demands an increasing awareness of ethical dilemmas and a model of medical training where communication, conflict-resolution, inclusive history taking, with assessment of patient values and preferences, is focussed on. The capacity for empathetic care has to be emphasized as an integral part of such approach. Finally, in this thesis, the concept of medical futility is tested and applied to clinical case scenarios. It is argued that the traditional medical paradigm, with its justification of an 'all out war' against disease and death, in order to achieve utopia for all, is outdated. Death in the neonatal intensive care unit is increasingly attributed to end-of-life decisions. Futile treatment could be considered a waste of scarce resources, contradicting the principle of nonmaleficence and justice, particularly in an African context. The ongoing confidence in, and uncritical submission to the technological progress in medicine is understood as a defence and coping mechanism against the backdrop of the experience of life's fragility, suffering and the inevitability of death. Such uncritical acceptance of the technological imperative could lead to a harmful fallacy that cure is effected by prolonging life at all cost. What actually occurs, instead, is the prolongation of the dying process, increasing suffering for all parties involved. The historical development of the concept of medical futility is discussed, highlighting its applicability to the paradigmatic scenario of cardio-pulmonary resuscitation. Particular attention is given to ways in which the concept could endanger patient-autonomy by allowing physicians to make unilateral, paternalistic decisions. It is argued that the informative model of the patient-physician relationship, where the physician's role is to disclose information in order for the patient to indicate her preferences, ought to be replaced by a more adequate deliberative model, where both / AFRIKAANSE OPSOMMING: Hierdie tesis bespreek die waarde van mediese futiliteit as 'n maatstaf vir aksie in gevalle van neonatale 'einde-van-lewe' besluite. Die konsep word gekontekstualiseer binne die wêreldbeskouing van mediese vooruitgang, die onsekerheid van mediese prognostikering en die probleme wat geassosieer IS met regverdige hulpbrontoekenning; spesifiek binne die unieke Afrika-situasie. Dit word aangevoer dat die tradisionele mediese paradigma, met regverdiging vir voorkoming van siekte en dood ten alle koste, verouderd is. Sterftes in neonatale intensiewe sorgeenhede word toenemend toegeskryf aan 'einde-van-lewe' besluite Futiele behandeling sou dus beskou kon word as 'n vermorsing van skaars hulpbronne, wat teenstrydig sou wees met die beginsels nie-skadelikheid ('nonmaleficence') en regverdigheid. Die volgehoue vertroue in en onkritiese aanvaarding van aansprake op tegnologiese vooruitgang lil geneeskunde, kan beskou word as verdediging- en hanteringsmeganisme in die belewenis van lewenskwesbaarheid, lyding en die onafwendbaarheid van die dood. Sodanige onkritiese aanvaarding van die tegnologiese imperatief kan tot 'n onverantwoordbare denkfout, naamlik dat genesing plaasvind deur verlenging van lewe ten alle koste, lei. Wat hierteenoor eerder mag plaasvind, is 'n verlenging die sterwensproses en, gepaard daarmee, toenemende lyding van all betrokke partye. Die historiese ontwikkeling van die konsep van mediese futiliteit word bespreek met klem op die toepaslikheid daarvan op die paradigmatiese situasie van kardiopulmonêre resussitasie. Spesifieke aandag word gegee aan maniere waarop die konsep pasiënte se outonomie in gevaar stel, deur die betrokke medici die reg te gee tot eensydige, paternalistiese besluitneming. Die argument is dan dat die informatiewe model, waar die verhouding tussen die dokter en pasiënt gebasseer is op die beginsel dat die dokter inligting moet verskaf aan die pasiënt sodat die pasiënt 'n ingeligte besluit kan neem, vervang moet word met 'n meer toepaslike beraadslagende model, waar sowel die dokter as die pasiënt aktief deelneem aan interaktiewe beraadslaging oor 'n aksieplan. Albei partye word dan moreel verantwoordbaar. So 'n model van beraadslaging het die bykomende voordeel dat dit die beperkings van die deelnemers kan transendeer. Sodoende word 'n hoër-vlak oplossing - iets meer as 'n blote consensus - te weeg gebring. Die argument word ontwikkel dat mediese vooruitgang meelewing met die sterwendes en hul geliefdes mag verberg. Verder dui die literatuur daarop dat die kwaliteit van einde-van-lewe-sorg vir sowel die pasiënte as hul familie onaanvaarbaar is. Dit is binne hierdie konteks dat die konsep van mediese futiliteit kan dien as 'n maatstaf vir aksie. Medici kan nie verantwoordelikheid vir deelname aan beraadslaging rondom eindevan- lewe beluitneming vermy nie, en as sodanig vereis die situasie toenemende bewustheid van sowel die etiese dilemmas as 'n mediese opleidingsmodel waann kommunikasie, konflikhantering, omvattende geskiedenis-neming, met insluiting van die pasient se waardes en voorkeure, beklemtoon word. Die kapasiteit vir empatiese sorg moet weer eens beklemtoon word as 'n integrale deel van hierdie benadering. Ten slotte, hierdie tesis poog om die konsep van mediese futiliteit te toets en toe te pas op kliniese situasies.

It is understood that the organization of perinatal care, according to the risk approach, implies that every pregnant and newborn are adequately cared for at the level of complexity they need. The purpose of the present study was to describe the structure and processes of care for pregnant women and newborns, including essential neonatal care, in maternity hospitals in the State of Sergipe. It is an integrated cross-sectional study to the research Born in Sergipe: survey about pre - natal, delivery and puerperium, conducted between June 2015 and April 2016 in public, mixed and private hospitals of Sergipe that had performed a minimum of 500 births in 2014, totaling 11 hospitals. Initially, a questionnaire was administered to managers of the eligible units on the existing structure and work processes. Subsequently, a representative number of postpartum women from these hospitals were interviewed and, after discharge, their medical records and those of their newborns were analyzed. The results showed that Sergipe has 78 beds of Neonatal Intensive Care Unit (NICU) and 90 Units of Intermediate Unit (UI) to meet spontaneous and programmed demand. Only six maternity hospitals (54.5%) performed the risk classification, and four (36.3%) had protocols for attending high-risk deliveries. Moreover, regarding components of the Essential Newborn Care corresponding strategies which aim to improve the health of the newborn at different stages, from conception to the postnatal period, only 18% of women had the presence of Companion always for delivery, 41% had skin-to-skin contact early with their child and 33.1% breastfed in the first hour of life. It was observed an adequate distribution of NICU beds between Capital and Interior considering the current legislation, low adherence to protocols of hypertensive and hemorrhagic emergencies; there was low coverage also for the humanization policies, risk rating for the pregnant woman and practices of Essential Newborn Care, especially the skin - to - skin contact and breastfeeding in the first hour of life. / A organização da assistência perinatal, segundo o enfoque de risco, implica que toda gestante e recém-nascido sejam atendidos adequadamente no nível de complexidade que necessitam. O presente estudo teve por objetivo descrever a estrutura e os processos de atendimento à gestante e ao recém-nascido, incluindo os cuidados neonatais essenciais, das maternidades do Estado de Sergipe. Trata-se de um estudo transversal integrado à pesquisa Nascer em Sergipe: inquérito sobre assistência pré-natal, parto e puerpério, realizado entre junho de 2015 e abril de 2016 nas maternidades públicas, mistas e privadas de Sergipe que tiveram pelo menos 500 partos em 2014, totalizando 11 maternidades. Inicialmente foi aplicado um questionário aos gestores das unidades elegíveis sobre a estrutura e os processos de trabalhos existentes. Posteriormente, um número representativo de puérperas desses hospitais foi entrevistado e, após a alta, seus prontuários e os de seus recém-nascidos foram analisados. Os resultados mostraram que Sergipe dispõe de 78 leitos de Unidade de Terapia Intensiva Neonatal (UTIN) e 90 de Unidade Intermediária (UI) para atendimento da demanda espontânea e programada. Somente seis maternidades (54,5%) realizam a classificação de risco e quatro (36,3%) possuem protocolos para atendimento das parturientes de alto risco. Além disso, os componentes do Essential Newborn Care que correspondem a estratégias que têm o objetivo melhorar a saúde do recém-nascido em diferentes estágios, desde a concepção até o período pós-natal, estavam presentes em apenas 18% das mulheres que tiveram a presença do acompanhante em todos os momentos do parto, 41% que tiveram contato pele a pele precoce com seu filho e 33,1% que amamentaram na primeira hora de vida. Observou-se uma distribuição adequada de leitos de UTIN entre Capital e Interior levando-se em consideração a legislação vigente, baixa adesão aos protocolos das emergências hipertensivas e hemorrágicas; houve baixa cobertura também em relação às políticas de humanização, classificação de risco para a gestante e às práticas do Essential Newborn Care, principalmente o contato pele a pele precoce e a amamentação na primeira hora de vida.

Necrotizing enterocolitis (NEC) is a costly and deadly disease in neonates. Composite risk for NEC is poorly understood and consensus has not been established on the relevance of risk factors. This two-phase study attempted to validate and test a neonatal NEC risk index, GutCheck(NEC). Phase I used an E-Delphi methodology in which experts (n=35) rated the relevance of 64 potential NEC risk factors. Items were retained if they achieved predefined levels of expert consensus or stability. After three rounds, 43 items were retained (CVI=.77). Qualitative analysis revealed two broad themes: individual characteristics of vulnerability and the impact of contextual variation within the NICU on NEC risk. In Phase II, the predictive validity of GutCheck(NEC) was evaluated using a sample from the Pediatrix BabySteps Clinical Data Warehouse (CDW). The sample included infants born<1500 grams, before 36 weeks, and without congenital anomalies or spontaneous intestinal perforation (N=58,818, of which n=35,005 for empiric derivation and n=23,813 for empiric validation). Backward stepwise likelihood-ratio method regression was used to reduce the number of predictive factors in GutCheck(NEC) to 11 and derive empiric weights. Items in the final GutCheck(NEC) were gestational age, history of a transfusion, NICU-specific NEC risk, late onset sepsis, multiple infections, hypotension treated with Inotropic medications, Black or Hispanic race, outborn status, metabolic acidosis, human milk feeding on both day 7 and day 14 (reduces risk) and probiotics (reduces risk).Discrimination was fair in the case-control sample (AUC=.67, 95% CI .61-.73) but better in the validation set (AUC=.76, 95% CI .75-.78) and best for surgical NEC (AUC=.84, 95% CI .82-.84) and infants who died from NEC (AUC=.83, 95% CI .81-.85). A GutCheck(NEC) score of 33 (range 0-58) yielded a sensitivity of .78 and a specificity of .74 in the validation set. Intra-individual reliability was acceptable (ICC (19) =.97, p<.001). Future research is needed to repeat this procedure in infants between 1500 and 2500 grams, complete psychometric testing, and explore unit variation in NEC rates using a comprehensive approach.

No description available.

The thesis presented here describes original research in the field of Natural Language Generation (NLG). NLG is the subfield of artificial intelligence that is concerned with the automatic production of documents from underlying data. This thesis in particular focuses on developing new and novel methods for generating text that takes into consideration the recipient’s level of stress as a factor to adapt the resultant textural output. This consideration of taking the recipient level of stress was particularly salient due to the domain that this research was conducted under; providing information for parents of pre-term infants during neonatal intensive care (NICU). A highly technical and stressful environment for parents where emotional sensitivity must be shown for the nature of information presented. We have investigated the emotional and informational needs of these parents through an extensive past literature review and two separate research studies with former and current NICU parents. The NLG system built for this research was called BabyTalk Family (BT-Family). A system that can produce a textual summary of medical events that has occurred for a baby in NICU in last twenty-four hours for parents. The novelty of this system is that is capable of estimating the level of stress of the recipient and by using several affective NLG strategies it is able to tailor it’s output for a stressed audience. Unlike traditional NLG systems where the output would remain unchanged regardless of emotional state of the recipient. The key innovation in this system was the integration of several affective strategies in the Document Planner for tailoring textual output for stress recipients. BT-Family’s output was evaluated with thirteen parents that previously had baby in neonatal care. We developed a methodology for an evaluation that involved a direct comparison between stressed and unstressed text for the same given medical scenario for variables such as preference, understandability, helpfulness, and emotional appropriateness. The results, obtained showed the parents overwhelming preferred the stressed text for all of the variables measured.

No description available.

Class of 2012 Abstract / Specific Aims: The purpose of this study is to evaluate and compare clinical outcomes and cost involved with use of poractant versus beractant for the treatment of respiratory distress syndrome (RDS) in a level III, neonatal intensive care unit (NICU) within an academic medical center. Methods: This retrospective cohort study included patients if they were admitted to the NICU for RDS between April 1, 2010 to November 30, 2010 and December 1, 2010 to June 30, 2011 treated with beractant and poractant respectively. Patients were excluded from the study if they were greater than 35 weeks gestational age and survived less than 48 hours. This is a review and the information needed from the patients was submitted in a data extraction form. Data collected included demographic variables (age, birthweight, birth length, gender, and race/ ethnicity), FiO2 measurement, mechanical ventilation time, length of hospitalization in the NICU, the incidence complications in the first 28 days, number of doses given, use of the nasal CPAP, concurrent complications or comorbidites such as pulmonary hemorrhage, bronchopulmonary dysplasia, patent ductus arteriosis, intraventricular hemorrhage, and retinopathy of maturity. Main Results: Data from 27 neonates in beractant and 13 in poractant groups were collected. The FiO2 measurements in both groups were generally similar. However, FiO2 was consistently lower in the poractant group. (p = 0.044 from a runs statistical test) Conclusions: The FiO2 measurement is poractant group was lower compared with beractant group, however the difference was noted to be not statistically significant.

M.Cur. / Please refer to full text to view abstract

Magister Curationis - MCur / Parents undergo negative experiences that include parental anxiety, depression, and posttraumatic stress when their new-born babies are hospitalised in neonatal intensive care unit. During this stressful period, parents need assistance from staff in order to cope. A quantitative, descriptive survey design was used to describe parents’ perception of nursing support during their baby’s admission in neonatal intensive care units (NICU) at three selected private hospitals in the city of Cape Town in the Western Cape Province. A structured existing 21- item Likert type questionnaire, the Nurse-Parent Support Tool (NPST) was used to collect data from an all-inclusive sample of 85 parents with a response rate of 78.8% (n=67). The purpose of the questionnaire was to determine their perception of information giving and communication by nurses; emotionally supportive behaviours by nurses; care given support or instrumental support and to identify parents’ perception of esteem or appraisal support while in the NICU environment. The data was analysed using Statistical Package for Social Sciences (SPSS) version 24. The findings of this study suggested that the overall mean score for parents’ perception of nursing support was high 4.6 (±0.5) out of a possible of 5. There was no significant difference in the overall mean perceived support score between the different facilities. No significant differences were found in terms of all the demographics characteristics with regard to perceptions of the support that was received, thus indicating that there was no relationship between the demographic variables and perception of support. The findings suggested that though high parental support was reported, the area of involving parents in the care of their babies i.e. letting them decide whether to stay or leave during procedures need improvement.