Your six to eight page paper should include the following

Your six to eight page paper should include the following elements: Title page in APA student format. Article reference (APA format) at the top of the first page Introduction:1-3paragraphs orienting the reader to the study a) Introduces the topic and clinical question/problem b) Provides background information c) Statesthepurposeoftheresearch d) Preview your analysis of the research with an appropriate thesis statement 1. Research Summary (no more than two pages): Brief summary of the study itself with sufficient detail to clearly explain the research a) Study design b) Study methodology (sampling, procedures, instrumentation, data collection, etc.) c) Main findings (statistic alanalysis and results) d) Authors’ conclusions e) Limitations, validity, and reliability addressed by authors 1. Critical analysis(approx.four – six pages):a balanced discussion of the strengths and weaknesses of the research, supported with specific examples from the study 1 RSH 350 – Critical Review Paper Instructions a) Introduction: broad analysis of introductory information of the study b) Methodology: analysis of study methods c) Results: analysis of statistical tests utilized and results reported d) Discussion: analysis of the validity, reliability, and limitations of the study and how well the researchers achieved their intended purpose 1. Conclusion: summary of the main points and the usefulness of the research 2. Additional elements to consider a) Include evidence from related sources to support your evaluation b) Provide a reference list for the source reviewed and additional sources cited in your paper. (no subject) Original Article Full Access Survival and neurodevelopmental outcomes in extremely preterm infants 22-24 weeks of gestation born in Western Australia Mary Sharp, Noel French, Judy McMichael, Catherine Campbell First published: 24 August 2017 https://doi.org/10.1111/jpc.13678Citations: 27 Conflict of interest: None declared. Sections PDF Tools Share AbstractAim The management of births at borderline viability continues to present dilemmas for health professionals and parents. The aim of the study was to review local outcomes of infants born between 22 and 24 weeks of gestation between 2004 and 2010 in Western Australia (WA) to aid perinatal counselling. Methods Survival data for the study were sourced retrospectively from the Neonatal Clinical Care Unit and Department of Health records of births in WA. Neurodevelopmental follow-up outcomes were assessed using the most recent standardised assessment (Griffiths, Bayley-III and Wechsler Preschool and Primary Scale of Intelligence, 3rd Ed) and medical examination of infants/children 12 months to 8 years from follow-up clinic appointments. Results At these gestations, 159 survivors represented 72% of neonatal intensive care unit admissions, 53% of WA live births and 26% of WA live and still births; 5% of live births survived at 22 weeks, 46% at 23 weeks and 77% at 24 weeks. Of the 14 outborn/retrieved infants, 4 survived (29%). At a median age of 59 months, disabilities were severe in 13% of children (22-23w = 19%; 24w = 11%). The median test quotient was 90. Moderate and severe cognitive disability was found in 16%, cerebral palsy was found in 7% (n = 11), and 55% of children were free from impairment as defined in this study. Conclusion At these gestations, survival figures varied markedly with the chosen population denominator. Regional data are essential for valid population comparison. While many developmental difficulties occurred in these children, 78% were free from moderate or severe impairment at ages 3-5 years. What is already known on this topic Extremely preterm birth is medically challenging and ethically contentious. There is a wide variation in published clinical practice guidelines. There is variation in reported survival and long-term outcomes between and within countries. What this paper adds This study included a geographical cohort from the state of WA describing survival and long-term outcomes for extremely preterm infants. A total of 72% of infants born <25 weeks and admitted to neonatal intensive care unit survived. A total of 78% of survivors were free from moderate-to-severe disability. Providing intensive care support for infants born at the extreme limits of survival, between the 22nd and 24th week of pregnancy, is both medically challenging and ethically contentious, reflected in the wide variation of published management guidelines.1 There has been improvement in the survival of extremely preterm births over the past decades.2-4 In a recent study of 11 neonatal centres from North America, improvements in the survival of preterm infants of a gestational age of 22-24 weeks were reported, with survival in the most recent epoch, 2008-2011, of 36% of live births.5 Interpreting these findings, however, is complicated by variability in treatment across the centres and the representativeness of the epochs and centres used (only 4-5% of periviable neonates in the USA).6 Survival and long-term outcome for extremely preterm infants varies between and within countries in regions that offer otherwise similar levels of intensive care support.7-9 Two studies published from Sweden8 and North America9 showed that survival figures were related to different levels of 'intensity' of active treatment between centres, with high-activity centres reporting better survival and better survival without severe impairment relative to low-activity centres.8, 9 Despite different definitions of what constitutes 'active treatment' (e.g. some studies refer to neonatal interventions only, while others define active treatment as a combination of obstetric and neonatal intervention), a large proportion of the individual differences between centres in reported survival rates and survival without severe disability for infants born at 22, 23 and 24 weeks of gestation is explained by the intensity of perinatal care.8, 9 The impact of 'high and low' activity treatment centres accounted for 78% of variance in survival rates and 75% of variance in survival without severe disability in 22- and 23-week infants. In addition, the effect size of 'intensity' of perinatal care was equivalent to, or larger than, the effect size of proven intervention, such as surfactant administration, antenatal corticosteroids or centralisation of perinatal care.8 However, this pattern of findings appears to attenuate by 24 weeks of gestation across both Swedish and North American studies.6, 7 In the multi-centre audit, centre differences explained only 22% of variance in survival and 16% of the variance in survival without disability in their 24 gestational week group.9 A recent study on variability in management and outcomes of extremely preterm births from five European countries also highlighted international variation in survival, provision of antenatal steroids and respiratory support.10 The intensity of treatment is also variable between practitioners within centres and between centres. Underestimating neonatal survival by obstetricians has been associated with reduced administration of corticosteroids, performing fewer caesarean sections for fetal distress and transferring fewer mothers to tertiary centres for delivery.11 Similarly, in paediatrics, underestimation of survival has been associated with less use of mechanical ventilation, cardio-pulmonary resuscitation, inotropes, intravenous fluids, thermal support and oxygen supplementation.12 It has also been reported that among births at 22 and 23 weeks, there are differences in decisions about treatment at the start and end of each gestational week, which may suggest, for both physician and for families, that 'rounding up' or 'rounding down' the gestational age impacts decision-making about treatment.9 Interpreting published survival and disability rates for children born at 22-24 weeks is thus complicated by such variations in obstetric and neonatal care. Published Australian studies of neonatal intensive care unit (NICU) admissions have reported survival of 11 of 41 (27%) infants at 23 weeks and 110 of 186 (59%) infants at 24 weeks in New South Wales and the Australian Capital Territory13 and survival of 11 of 16 (69%) infants at 23 weeks and 41 of 71 (58%) infants at 24 weeks in Victoria.14 Interpretation of survival and long-term outcomes are also complicated by use of varying population denominators, such as individual NICU admissions, regional NICU admissions, hospital births or regional births.15 Studies vary in the assessment of developmental impairments, differences in measurement, age of measurement, use of corrected versus chronological age, use of normative comparison groups and differences in classification and differentiation of neurosensory impairments. These differences make interpreting complex data difficult when drawing generalised conclusions for the purpose of informing counselling information for parents.15 The impetus for the current study was to carry out a clinical audit of survival and long-term outcomes of infants born at the extreme limits of viability and to provide appropriate data for parental counselling for our region. The primary aim of the current study was to review the survival and long-term outcomes of infants born between 22 and 24 completed weeks of gestation in WA born between 2004 and 2010. Long-term outcomes were assessed using the most recent standardised developmental/cognitive assessment available. The NICU at King Edward Memorial Hospital (KEMH) has historically had an 'active' culture about the initiation of intensive care support to liveborn infants at borderline levels of maturity. Methods We conducted a regional-based long-term follow-up audit of all surviving infants born at 22, 23 and 24 weeks of gestation in Western Australia (WA), between 2004 and 2010, born at or transferred to the State's only tertiary perinatal unit at KEMH. Live births delivered at KEMH were coded as 'inborn'. Live births delivered at any other hospital were coded as 'outborn'. No infants were born in transit to KEMH, and there were no recorded survivors at these gestations who were not admitted to KEMH. Morbidity data were collected at the time of hospital discharge, including transfer to other neonatal care levels up to the age of 12 months. No major congenital malformations were identified in survivors of this group. Neonatal morbidity was not, however, examined in the current audit. This audit was approved by the North Area Metro Health (KEMH) Human Research Ethics Committee (GEKO reference 10598). Neonatal data source Data were sourced retrospectively from the neonatal database at KEMH. WA is the largest Australian state, with a land area of 2 529 875 km2. Tertiary obstetric and neonatal care is highly centralised in WA, with a single perinatal unit providing such care. This unit also provides long-term follow-up on all survivors. Survival and follow-up data from the hospital and follow-up databases were retrieved for this review. Intensive care support is offered to infants from 23 weeks onwards with parental consent. There is written material available for parents at risk of delivering an extremely preterm infant to support antenatal consultations with the obstetric and neonatal teams. Intensive care admission was not routinely provided to infants born at 22 weeks of gestation, although it occasionally occurred during this period (n = 5). Midwives in WA are required to report all births, including stillbirths, to the WA Department of Health, and data on all births including stillbirths from 2004 to 2010 were obtained from the Midwives Notification System.16-20 Follow-up procedures The KEMH Neonatal Follow-up Program is offered to all <25 week infants for developmental and medical review at 12 months, 24 months, 36 months and 5 years of age, which included a standardised developmental assessment plus a medical review of the child's general health, growth and neurological status. All measures were administered under standardised conditions by trained and accredited personnel of the Neonatal Follow-up Program. Each measure is comprised of standard psychometric properties based on published norms, with a mean of 100 and a standard deviation of 15, with the exception of the 0-2-year Griffiths test, which has a mean of 100 and a standard deviation of 12. Mild developmental/cognitive impairment was defined as a test quotient >1-2 standard deviations below the mean, moderate impairment as >2-3 standard deviations below the mean and severe impairment as >3 standard deviations below the mean. The most recent quotient score was analysed for each child. Age correction for prematurity was undertaken at all ages. Children who were assessed in the clinic and were unable to complete a formal standardised assessment due to disability were assigned a proxy quotient value of 49 (>3 standard deviations below the mean). Measures The Griffith Mental Development Scale, Revised (GMDS-R 0-2 years and GMDS-ER 2-8 years)21 was administered by accredited developmental paediatricians to obtain an aggregate general quotient of development at 12 and 36 months, corrected for preterm birth. Bayley Scales of Infant and Toddler Development, 3rd Ed (Bayley-III)22 was administered by psychologists at 24 months, corrected for preterm birth. While all scales were administered, the cognitive composite score was analysed in the current review. Wechsler Preschool and Primary Scale of Intelligence, 3rd Ed (WPPSI-III)23 was administered by psychologists to obtain the aggregate full-scale IQ (FSIQ) at age 5 years, corrected for preterm birth. Outcomes Long-term outcomes for surviving infants are reported as follows. Impairment in cognitive development was classified according to standard deviations from the mean on standardised developmental assessment (see above) at four levels – no impairment, mild, moderate and severe impairment. Cerebral palsy (CP) was defined clinically as a non-progressive disorder of movement and posture in the presence of abnormalities of tone and, where possible, was classified using the Gross Motor Functional Classification System.24 CP status was verified against the WA CP register, now incorporated into the West Australian Register of Developmental Anomalies.25 Hearing status was classified at three levels – no impairment, unilateral hearing loss and bilateral loss requiring hearing amplification (aides/cochlear implants). Visual disability was defined as acuity less than 6/60 in the better eye. Autism was not specifically assessed but classified as a severe outcome if known to be present and diagnosed by standard multidisciplinary team assessment (Table 1). Table 1. Definitions of disability Impairment level Mild Moderate Severe Cognitive delay >1-2 SD below test mean >2-3 SD below test mean >3 SD below test mean Cerebral palsy Ambulant GMFCS level I/II Ambulant with aids GMFCS level III Non-ambulant GMFCS level IV/IV Deafness Unilateral Bilateral requiring hearing amplification Blindness Vision less than 6/60 Autism Present GMFCS, Gross Motor Function Classification System. Results Survival of total births, live births and NICU admissions at each week of gestation is shown in Table 2. There were 614 infants born at 22-24 weeks in WA in 2004-2010. Of these, 302 were liveborn (LB) and 312 were stillborn (SB). Of the liveborn, 222 were admitted to the NICU, and 159 survived. Two infants were born with major anomalies, and both died. Survival rate at 22-24 weeks clearly varied with the chosen population denominator, being 24% of all births (LB + SB), 53% of all live births and 72% of all NICU admissions at these gestations. Table 2. Survival for infants born at 22-24 weeks in 2004-2010 in Western Australia Gestation 22 weeks 23 weeks 24 weeks All n (survival %) n (survival %) n (survival %) n (survival %) Total survival (n) 3 44 112 159 All births (LB + SB) 227 (1.3) 188 (23) 199 (56) 614 (24) All live births 60 (5) 96 (46) 146 (77) 302 (53) All NICU admissions 5 (60) 78 (56) 139 (81) 222 (72) LB, live births; NICU, neonatal intensive care unit; SB, stillbirths. At 23 weeks, 56% of NICU admissions survived, rising to 81% at 24 weeks. Of 40 outborn infants who were liveborn, 14 (35%) were transferred and admitted to the NICU at KEMH, 4 (10%) of whom survived. Survival of the outborn infants admitted to NICU was 4 out of 14 (29%). There were no recorded survivors <25 weeks who were not admitted to the NICU. Of the 159 survivors, follow-up information beyond 12 months of age was available for 152 (96%). At 12 months corrected age, 78% of infants returned for their developmental follow-up assessment, 72% returned at 24 months, 67% at 36 months and 66% at 5 years. The most recent assessment was 12 months for seven (4.5%) and 24 months for five (3%). At least one formal assessment was completed between 3 and 5 years on 82% of survivors. The breakdown of data source for assessment score used in the analysis is presented in Table 3. The most recent test result available was used. Table 3. Latest test by gestational age Test 22 weeks 23 weeks 24 weeks Total n (%) n (%) n (%) n (%) Standard follow-up GMDS-R (12 m) — 4 (9) 3 (3) 7 (4.5) Bayley-III (24 m) — 1 (2) 4 (3.5) 5 (3) GMDS-ER (36 m) — 9 (20.5) 13 (12) 22 (14) WPPS-III (5 years) 2 (66) 25 (57) 79 (70.5) 106 (66.5) Alternative tests Leiter 1 (33) — 2 (1.5) 3 (2) WISC-IV — 2 (4.5) 2 (1.5) 4 (2.5) No test 0 3 (7) 9 (8) 12 (7.5) Total 3 44 112 159 —, Not available; GMDS-ER, Griffith Mental Development Scale-Extended Revised; GMDS-R, Griffith Mental Development Scale-Revised; WISC-IV, Wechsler Intelligence Scale for Children 4th Edition; WPPS, Wechsler Preschool and Primary Scale of Intelligence. There were 12 children not seen, for whom parent information was available on 5, all resident overseas or interstate. Of these five, four are known to have severe disability (severe visual impairment, two; autism, one; severe cognitive impairment, one). Information from one child, through regular email contact, indicated normal progress in school in the USA at 10 years. Seven children (4%) had no follow-up information available. The median age of the latest assessment was 59 months (interquartile range: 55-62), and a summary of developmental outcomes is shown in Table 4. Overall, of the 152 participants with follow-up information available, 43% met our disability criteria (22 weeks, 67%; 23 weeks, 56%; 24 weeks, 36%), almost half of these falling in the mild category (20%). Table 4. Long-term outcome results Gestational age 22 weeks 23 weeks 24 weeks All Survivors, n 3 44 112 159 Overall outcome, n (%) Outcome assessed in F/Up Program 3 (100) 41 (85) 103 (92) 147 (93) Outcome known assessed elsewhere†0 3 2 5 Outcome unknown 0 0 7 7 Corrected median age at last assessment, months, median (IQR) 59 (57-122) 58 (39-62) 59 (56-61) 59 (55-62) Last assessment, median quotient (IQR) 81 (87-114) 85 (72-93) 95 (79-105) 90 (78-104) Cognitive disability, n (%) Nil 1 (33) 21 (48) 68 (61) 90 (57) Mild 1 (33) 10 (23) 21 (19) 32 (20) Moderate 1 (33) 5 (11) 6 (5) 12 (8) Severe 0 6 (14) 9 (8) 15 (9) Cerebral palsy, n (%) Mild GMFCS I/I 0 2 6 8 Moderate GMFCS III 0 0 1 1 Severe GMFCS IV/V 0 1 1 2 Total 0 3 (7) 8 (7) 11 (7) Other disability, n Mild 0 1 2 3 Moderate 1 1 2 4 Severe 0 5 6 11 Overall disability, n (%) Mild 1 (33) 11 (25) 21 (19) 32 (20) Moderate 2 (67) 5 (11) 5 (5) 12 (8) Severe 0 9 (21) 12 (11) 21 (13) Free of moderate/severe disability 1 (33) 30 (68) 84 (83) 118 (78) †Severe visual disability, n = 2; autism, n = 1; severe cognitive disability, n = 1; normal school progress, n = 1. F/Up, follow up; GMFCS I/I, Gross Motor Function Classification System levels 1 and 2; GMFCS III, Gross Motor Function Classification System level 3; GMFCS IV/V, Gross Motor Function Classification System levels 4 and 5. Cognitive disability was the largest disability category, affecting 59 of 152 (39%), more than half of whom were in the mild category. Cognitive disability in the moderate or severe range, that is, >2 standard deviations below the test mean, was seen in 27 children (overall, 18%; 22 weeks, 33%; 23 weeks, 27%; 24 weeks, 15%). CP was present in 11 children (7%), of whom 9 were ambulant with or without some support (GMFCS level 1-3). CP type included diplegia (8), hemiplegia (2) and other (1). In accordance with the definitions, 119 (78%) survivors were free from moderate or severe disability (22 weeks, 33%; 23 weeks, 68%; 24 weeks, 84%). Hearing impairment that required hearing aids was identified in four children (2.5%); severe visual disability was identified in two children (1.3%); and autism had been diagnosed in nine children (5.6%). A combined outcome of either death or moderate-to-severe disability was seen in 43% of <25w NICU admissions. Discussion Survival and neurodevelopmental outcomes following birth at 22-24 weeks of gestation in a geographically defined cohort during 2004-2010 were reported in the current study. The survival and disability-free outcomes compared favourably to recently published results from Sweden,8 North America9 as well as single-centre studies from Japan.26, 27 More locally, survival following NICU admissions in WA (44/78 or 56% at 23 weeks and 112/139 or 81% at 24 weeks) is higher than reported survival from NSW and ACT (11/41 or 27% at 23 weeks and 110/186 or 59% at 24 weeks) over a similar time period, 2007-2011,13 and is similar to reported survival from NICU admissions in Victoria from 2010 to 2011 (11/16 or 69% at 23 weeks and 41/71 or 58% at 24 weeks).14 The major findings from this study provide a challenge to commonly held beliefs about survival and long-term outcomes of children born at the limits of viability, before 25 weeks of gestation. The majority of children born alive and admitted to NICU for care survived without moderate or severe disability (78%). CP among this group was less common than expected (7%). Mild cognitive delay (1-2 standard deviations below the test mean) was the most common adverse outcome of our 159 survivors (21%). While classified here as a 'mild delay', 1-2 standard deviations from the mean represent psychometric properties within the 'normal' population range, with 15% of the general population falling in this range of performance on the same measures. Clinically, this often translates to children who develop without significant disability but who may struggle with learning at school and/or show complex learning and behavioural problems.28 This has considerable implications for how clinicians choose to guide parents when making decisions about perinatal care of at-risk pregnancy and at the time of preterm labour. Notwithstanding optimistic disability-free survival, one in five survivors (20%) showed cognitive delay in the moderate or severe range (more than 2 standard deviations below the mean), this being the well-accepted criterion for intellectual disability. This report has emphasised the importance of considering the population denominator used to describe survival following extremely preterm birth, varying from 24 to 72% for our population. It is essential to use the same denominator when comparing results between studies.6 The high rate of follow-up was a strength of this study. Follow-up information beyond 12 months corrected age was available for 92% of survivors, which included standardised neurodevelopmental assessment of 93% of survivors who returned for follow-up. Children lost to follow-up have been variably reported as either less29 or more30-32 likely to have neurodevelopmental difficulties. The age of follow-up assessment, in so much as it provides an index of developmental maturity and stabilising trajectories, is important when considering long-term follow-up data (including the correction of chronological age to reflect maturation of a preterm infant).33 Older children provide more robust performance on measures of development and intelligence. One of the strengths of the current study is the median age of follow-up of 59 months. Many similar studies of children born extremely preterm provide neurodevelopmental outcomes between 18 and 30 months, usually in an effort to reduce attrition from follow-up.15 It has previously been reported that high-risk infants have the potential for the recovery of cognitive and academic performance with increasing age,15 with fewer children at age 8 years than at 20 months having cognitive impairment.34 The influences on survival and outcome are likely to be multi-factorial. Family genetics, stable and loving home environment, access to education and support, mental health, community health etc. are all likely to play significant roles in the long-term outcome of children, both those born with and without significant disability.35 There are a number of limitations to the current study. In this study, it was not possible to differentiate mortalities in the labour ward due to failed active resuscitation from those where the parents had not wished for active obstetric and neonatal intervention. The absence of a control cohort of term infants led to a reliance on test norms, most of which have not been standardised for Australian children. In particular, psychometric issues with the representativeness of the Bayley-III have been reported to show an overestimation of development in term 24-month-old infants and an underestimation of developmental delay.34, 36-38 We acknowledge that there are many disorders of behaviour and learning not captured in the classification of disability used in the present report. Furthermore, combining results from various measures, while enhancing cohort retention for reporting, may tap into different developmental parameters and constructs at different ages. However, we believe these differences are mitigated by the later age of assessment for our cohort than many other such studies as well as our focus on detection of moderate-to-severe disability for the purpose of perinatal counselling. Conclusion During the years 2004-2010, 53% of infants born alive at <25 weeks gestation in WA survived. Of NICU admissions, 72% survived, and 78% of these survivors were free from moderate-to-severe disability as defined at 5 years of age. We believe these figures provide justification for continuing to offer parents of these infants an informed choice about obstetric and neonatal intensive care support in WA.

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