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Maternal tobacco smoking and maternal exposure to combusted tobacco vapour are associated with adverse maternal, placental, foetal and neonatal outcomes, with sequelae through childhood and adolescence[sup.1?10] and into adulthood.[sup.11?16] Reducing [...], : Objective: To describe the placental characteristics and neonatal outcomes of Central Australian Aboriginal women based on maternal self?report of tobacco use. Methods: Placental and neonatal variables were collected from a prospective maternal cohort of 19 smokeless tobacco chewers, 23 smokers and 31 no?tobacco users. Results: Chewers had the lowest placental weight (460 g) while the no?tobacco group had the heaviest placental weight (565 g). Chewers and the no?tobacco group had placental areas of similar size (285 cm[sup.2] and 288 cm[sup.2] , respectively) while the placentas of smokers were at least 13 cm[sup.2] smaller (272 cm[sup.2] ). There were two stillbirths in the study and more than one?third (36%) of neonates (newborns) were admitted to the Special Care Nursery, with the chewers? neonates having a higher admission rate compared with smokers? neonates (44% vs. 23%). The cohort mean birthweight (3348 g) was not significantly different between the groups. When stratified for elevated maternal glucose, the chewers? neonates had the lowest mean birthweight (2906 g) compared to the neonates of the no?tobacco group (3242 g) and smokers (3398 g). Conclusions: This research is the first to demonstrate that the maternal use of Australian Nicotiana spp. (pituri) as smokeless tobacco may negatively impact placental and neonatal outcomes. Implications for public health: Maternal smokeless tobacco use is a potential source of placental and foetal nicotine exposure. Maternal antenatal screening should be expanded to capture a broader range of tobacco and nicotine products, and appropriate cessation support is required.

Abstract Aims To describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients. Background There are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders. Design/Methods A mixed methods triangulated convergent design. In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase. Conclusion This project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

Abstract The harmful outcomes of nicotine self administration have been the focus of sustained global health education campaigns that have targeted tobacco smoking and to a lesser extent, smokeless tobacco use. 'Smokeless tobacco' infers that the nicotine is not burnt, and administration can be through a range of methods including chewing. The chewing of wild tobacco plants (Nicotiana spp.) is practiced across a broad inland area of Central Australia by traditional Aboriginal groups. Collectively these plants are known by a variety of names - one common name being 'pituri'. This is the first paper to examine the historical literature and consider the linkage between pituri use and health outcomes. Using a narrative approach, this paper reviews the literature generated since 1770 surrounding the term pituri and the behaviours associated with its use. The review examines the scientific literature, as well as the diaries and journals of nineteenth century explorers, expedition notes, and early Australian novels to expound the scientific evidence and broaden the sense of understanding related to pituri, particularly the behavioural elements. The evaluation considers the complexities of ethnobotany pertaining to language and distance and the ethnopharmacology of indigenous plant usage. The review compares the use of burnt and smokeless tobacco to pituri and establishes the foundation for research into the clinical significance and health outcomes of pituri use. Additionally, this review provides contemporary information for clinicians providing care for patients who chew pituri.

Background: Respiratory failure or respiratory distress in infants is the most common reason for non-elective admission to hospitals and neonatal intensive care units. Non-invasive methods of respiratory support have become the preferred mode of treating respiratory problems as they avoid some of the complications associated with intubation and mechanical ventilation. High flow nasal cannula (HFNC) therapy is increasingly being used as a method of non-invasive respiratory support. However, the evidence pertaining to its use in term infants (defined as infants ≥ 37 weeks gestational age to the end of the neonatal period (up to one month postnatal age)) is limited and there is no consensus of opinion regarding the safety and efficacy HFNC in this population., Objectives: To assess the safety and efficacy of high flow nasal cannula oxygen therapy for respiratory support in term infants when compared with other forms of non-invasive respiratory support., Search Methods: We searched the following databases in December 2022: Cochrane CENTRAL; PubMed; Embase; CINAHL; LILACS; Web of Science; Scopus. We also searched the reference lists of retrieved studies and performed a supplementary search of Google Scholar., Selection Criteria: We included randomised controlled trials (RCTs) that investigated the use of high flow nasal cannula oxygen therapy in infants ≥ 37 weeks gestational age up to one month postnatal age (the end of the neonatal period)., Data Collection and Analysis: Two review authors independently assessed trial eligibility, performed data extraction, and assessed risk of bias in the included studies. Where studies were sufficiently similar, we performed a meta-analysis using mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). For statistically significant RRs, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to evaluate the certainty of the evidence for clinically important outcomes., Main Results: We included eight studies (654 participants) in this review. Six of these studies (625 participants) contributed data to our primary analyses. Four studies contributed to our comparison of high flow nasal cannula (HFNC) oxygen therapy versus continuous positive airway pressure (CPAP) for respiratory support in term infants. The outcome of death was reported in two studies (439 infants) but there were no events in either group. HFNC may have little to no effect on treatment failure, but the evidence is very uncertain (RR 0.98, 95% CI 0.47 to 2.04; 3 trials, 452 infants; very low-certainty evidence). The outcome of chronic lung disease (need for supplemental oxygen at 28 days of life) was reported in one study (375 participants) but there were no events in either group. HFNC may have little to no effect on the duration of respiratory support (any form of non-invasive respiratory support with or without supplemental oxygen), but the evidence is very uncertain (MD 0.17 days, 95% CI -0.28 to 0.61; 4 trials, 530 infants; very low-certainty evidence). HFNC likely results in little to no difference in the length of stay at the intensive care unit (ICU) (MD 0.90 days, 95% CI -0.31 to 2.12; 3 trials, 452 infants; moderate-certainty evidence). HFNC may reduce the incidence of nasal trauma (RR 0.16, 95% CI 0.04 to 0.66; 1 trial, 78 infants; very low-certainty evidence) and abdominal overdistension (RR 0.22, 95% CI 0.07 to 0.71; 1 trial, 78 infants; very low-certainty evidence), but the evidence is very uncertain. Two studies contributed to our analysis of HFNC versus low flow nasal cannula oxygen therapy (LFNC) (supplemental oxygen up to a maximum flow rate of 2 L/min). The outcome of death was reported in both studies (95 infants) but there were no events in either group. The evidence suggests that HFNC may reduce treatment failure slightly (RR 0.44, 95% CI 0.21 to 0.92; 2 trials, 95 infants; low-certainty evidence). Neither study reported results for the outcome of chronic lung disease (need for supplemental oxygen at 28 days of life). HFNC may have little to no effect on the duration of respiratory support (MD -0.07 days, 95% CI -0.83 to 0.69; 1 trial, 74 infants; very low-certainty evidence), length of stay at the ICU (MD 0.49 days, 95% CI -0.83 to 1.81; 1 trial, 74 infants; very low-certainty evidence), or hospital length of stay (MD -0.60 days, 95% CI -2.07 to 0.86; 2 trials, 95 infants; very low-certainty evidence), but the evidence is very uncertain. Adverse events was an outcome reported in both studies (95 infants) but there were no events in either group. The risk of bias across outcomes was generally low, although there were some concerns of bias. The certainty of evidence across outcomes ranged from moderate to very low, downgraded due to risk of bias, imprecision, indirectness, and inconsistency., Authors' Conclusions: When compared with CPAP, HFNC may result in little to no difference in treatment failure. HFNC may have little to no effect on the duration of respiratory support, but the evidence is very uncertain. HFNC likely results in little to no difference in the length of stay at the intensive care unit. HFNC may reduce the incidence of nasal trauma and abdominal overdistension, but the evidence is very uncertain. When compared with LFNC, HFNC may reduce treatment failure slightly. HFNC may have little to no effect on the duration of respiratory support, length of stay at the ICU, or hospital length of stay, but the evidence is very uncertain. There is insufficient evidence to enable the formulation of evidence-based guidelines on the use of HFNC for respiratory support in term infants. Larger, methodologically robust trials are required to further evaluate the possible health benefits or harms of HFNC in this patient population., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Preterm infants and neonates with respiratory conditions commonly require intubation and conventional mechanical ventilation (CMV) to maintain airway patency and support their respiration. Whilst this therapy is often lifesaving, it simultaneously carries the risk of lung injury. The use of lung recruitment manoeuvres (LRMs) has been found to reduce the incidence of lung injury, and improve oxygenation and lung compliance in ventilated adults. However, evidence pertaining to their use in neonates is limited, and there is no consensus of opinion as to whether LRMs are appropriate or effective in this population., Objectives: To determine the effects of LRMs on mortality and respiratory outcomes in mechanically ventilated neonates, when compared to no recruitment (routine care).  SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to 13 April 2020), and CINAHL via EBSCOhost (1989 to 13 April 2020). We also handsearched the reference lists of retrieved studies to source additional articles.  SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and randomised cross-over studies that compared the effect of LRMs to no recruitment (routine care) in mechanically ventilated neonates., Data Collection and Analysis: Two review authors independently assessed trial eligibility, extracted data and evaluated risk of bias in the included studies. When studies were sufficiently similar, we performed a meta-analysis using mean difference (MD) for continuous data and risk ratio (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of the evidence for key (clinically important) outcomes., Main Results: We included four studies (152 participants in total) in this review. Three of these studies, enrolling 56 participants, contributed data to our prespecified outcomes. Two studies enrolling 44 participants on CMV for respiratory distress syndrome compared a stepwise LRM with positive end-expiratory pressure (PEEP) to routine care. Meta-analysis demonstrated no evidence of a difference between the LRM and routine care on mortality by hospital discharge (RR 1.00, 95% CI 0.17 to 5.77; low-certainty evidence), incidence of bronchopulmonary dysplasia (RR 0.25, 95% CI 0.03 to 2.07; low-certainty evidence), duration of supplemental oxygen (MD -7.52 days, 95% CI -20.83 to 5.78; very low-certainty evidence), and duration of ventilatory support (MD -3.59 days, 95% CI -12.97 to 5.79; very low-certainty evidence). The certainty of the evidence for these outcomes was downgraded due to risk of bias, imprecision, and inconsistency. Whilst these studies contributed data to four of our primary outcomes, we were unable to identify any studies that reported our other primary outcomes: duration of continuous positive airway pressure therapy, duration of neonatal intensive care unit stay, and duration of hospital stay.  The third study that contributed data to the review enrolled 12 participants on CMV for respiratory and non-respiratory causes, and compared two different LRMs applied after endotracheal tube suctioning to routine care. It was determined that both LRMs may slightly improve end-expiratory lung volume at 120 minutes' post-suctioning, when compared to routine care (incremental PEEP LRM versus routine care: MD -0.21, 95% CI -0.37 to -0.06; double PEEP LRM versus routine care: MD -0.18, 95% CI -0.35 to -0.02). It was also demonstrated that a double PEEP LRM may slightly reduce mean arterial pressure at 30 minutes' post-suctioning, when compared with routine care (MD -16.00, 95% CI -29.35 to -2.65).  AUTHORS' CONCLUSIONS: There is insufficient evidence to guide the use of LRMs in mechanically ventilated neonates. Well-designed randomised trials with larger sample sizes are needed to further evaluate the potential benefits and risks of LRM application in this population., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Introduction: Tobacco smoking has a range of known and predictable adverse outcomes, and across the world sustained smoking reduction campaigns are targeted towards reducing individual and public risk and harm. Conversely, more than 87 million women, mostly in low- and middle-income countries, use smokeless tobacco, yet the research examining the effect of this form of tobacco exposure on women is remarkably scant. In central Australia, the chewing of wild Nicotiana spp., a tobacco plant, commonly known as pituri and mingkulpa, is practised by Aboriginal groups across a broad geographical area. Until recently, there had been no health research conducted on the effects of chewing pituri., Methods: This article reports on one component of a multidimensional pituri research agenda. A narrative approach utilising the methodology of the Learning Circle was used to interview three key senior central Australian Aboriginal women representative of three large geographical language groupings. The participants were selected by a regional Aboriginal women's organisation. With the assistance of interpreters, a semistructured interview, and specific trigger resources, participants provided responses to enable an understanding of the women's ethnobotanical pituri knowledge and practices around the use of pituri within the context of Aboriginal women's lives. Data were transcribed, and by using a constant comparison analysis, emergent themes were categorised. The draft findings and manuscript were translated into the participants' language and validated by the participants., Results: Three themes around pituri emerged: (a) the plants, preparation and use; (b) individual health and wellbeing; and (c) family and community connectedness. The findings demonstrated similar participant ethnobotanical knowledge and practices across the geographical area. The participants clearly articulated the ethnopharmacological knowledge associated with mixing pituri with wood ash to facilitate the extraction of nicotine from Nicotiana spp., the results of which were biochemically verified. The participants catalogued the pleasurable and desired effects obtained from pituri use, the miscellaneous uses of pituri , as well as the adverse effects of pituri overdose and toxicity, the catalogue of which matched those of nicotine. The participants' overarching pituri theme was related to the inherent role pituri has in the connectiveness of people to family, friends and community., Conclusions: Central Australian Aboriginal women have a firmly established knowledge and understanding of the pharmacological principles related to the content of Nicotiana spp. and the extraction of nicotine from the plant. Widespread use of Nicotiana spp. as a chewing tobacco by Aboriginal populations in the southern, central and western desert regions of Australia is attested to by participants who assert that everyone uses it , with girls in these remote areas commencing use between 5 and 7 years of age. Central Australian Aboriginal people who chew Nicotiana spp. do not consider it to be a tobacco plant, and will strongly refute that they are tobacco users. Central Australian Aboriginal people do not consider that the Western health information regarding tobacco (as a smoked product) is applicable or aligned to their use of pituri . Nicotiana spp. users will deny tobacco use at health assessment. There is a requirement to develop and provide health information on a broader range of tobacco and nicotine products in ways that are considered credible by the Aboriginal population. Health messages around pituri use need to account for the dominant role that pituri occupies in the context of central Australian Aboriginal women's lives., Information for readers: A consultative organisation of Aboriginal women has as a strategic intent and operational agenda the improvement of Aboriginal women's and children's health across the research region. The group seeks opportunities to enhance their knowledge based on legitimate collaborative research; accordingly, they sought to participate in a range of research activities regarding the use of pituri and women's health outcomes. Of particular note, the group's participants chose to be identified by name in the publication of this research activity. In this article, the term 'Aboriginal' has been chosen by the central Australian women to refer to both themselves and the Aboriginal people in their communities; 'Indigenous' has been chosen to refer to the wider Australian Aboriginal and Torres Strait Islander people. The term Nicotiana spp. is used when referring to the plants from a Western perspective; pituri is used when referring to the plants, the tobacco quid, and the practice of chewing from a general Aboriginal perspective; and mingkulpa is used when the participants are voicing their specific knowledge and practices.