Objective: To investigate whether exothermic sodium acetate mattresses were associated with an improvement in the thermal care of babies <30 weeks gestation between birth and admission to a neonatal unit.Study Design: Analysis of a three case series of babies: the first with traditional thermal care of drying and wrapping in a towel, the second with wrapping in food standard polythene bags and the third with wrapping in polythene bags and nursing on an activated exothermic mattress. The main outcome measure was the temperature on admission to the neonatal unit.Result: There were no significant differences between the groups for gestation and birth weight. Hypothermia was less frequent in the 'bag and mattress' group compared with the 'bag only' and traditional care groups (26 vs 69 vs 84%, respectively) even though the median time to admission was longest in the 'bag and mattress' group (23 min). The proportions of babies admitted with temperatures in the target range of 36.5 to 37.5 1C were 46, 27 and 16%, respectively. Multiple regression analysis showed that use of the mattress raised admission temperatures by 1.04 1C. The median temperature of babies in the 'bag and mattress' group was higher compared with the other groups (36.9 vs 36.0 vs 35.8 1C), but significantly more were hyperthermic (28 vs 4 and 0.4%, respectively).Conclusion: Use of exothermic mattresses for babies <30 weeks gestation was associated with a significantly greater proportion of babies being admitted to the neonatal unit with a temperature in the euthermic range, but there was also an increased risk of hyperthermia.

An infant was born at 33+2 weeks gestation by caesarean section after an in utero diagnosis of fetal ascites and tachycardia. The mother had received treatment during pregnancy with flecainide, amiodarone, and propranolol. The amiodarone was prescribed initially at 200 mg three times a day and was reduced to twice a day after 11 days. The mother was keen to breast feed the baby. In previous reports of amiodarone and breast feeding, amiodarone treatment was for a maternal indication and hence continued post partum. 1 2 In this case, the amiodarone treatment stopped at delivery. However, because of the long terminal half life of amiodarone (about 50 days 3), it could take several months for the level to fall. As one of the adverse effects of amiodarone is thyroid toxicity, the baby's thyroid function was assessed and found to be normal. A decision was made to allow the mother to breast feed, and the baby was closely monitored. Breast milk was sent for analysis to determine the amiodarone level on days 5, 11, 18, and 25. It had increased on day 11 (2.1 mg/l) compared with day 5 (0.6 mg/l). This may be due to changes in composition of the milk. We do not know at what time of day the milk was expressed or whether the sample was taken at the beginning or the end of the feed. The fat content of the milk was likely to be greater after 11 days than after 5 days, which may affect the distribution of amiodarone. McKenna et al 4 described changes in amiodarone concentration in breast milk throughout the day. By 25 days, amiodarone was undetectable. Throughout this period the baby remained well and thyroid function was normal. Although we would not recommend that breast feeding is necessarily safe for all babies exposed to amiodarone, this case illustrates that, in some circumstances, with close monitoring, breast feeding can be initiated.

A retrospective study was designed to compare the incidence of urinary tract infections during two different time periods in burn patients treated with two different types of Foley catheters. In time period 1, latex catheters present on admission were not changed. In time period 2, catheters were replaced on admission with silver alloy-impregnated catheters. In time period 1, the rate of symptomatic urinary tract infections was 7.2 per 1,000 catheter-days. In time period 2, the rate was 4.4 per 1,000 catheter-days. Results, compared using Fisher's exact test, revealed a statistically significant P value of .029. The use of silver-impregnated catheters significantly lowered the rate of urinary tract infection at our burn center.

The patient-centered medical home (PCMH) is a primary care model that aims to provide quality care that is coordinated, comprehensive, and cost-effective. PCMH is hinged upon building a strong patient-provider relationship and using a team-based approach to care to increase continuity and access. It is anticipated that PCMH can curb the growth of health care costs through better preventative medicine and lower utilization of services. The Navy, Air Force, and Army are implementing versions of PCMH, which includes the use of technologies for improved documentation, better disease management, improved communication between the care teams and patients, and increased access to care. This article examines PCMH in the Military Health System by providing examples of the transition from each of the branches. The authors argue that the military must overcome unique challenges to implement and sustain PCMH that civilian providers may not face because of the deployment of patients and staff, the military's mission of readiness, and the use of both on-base and off-base care by beneficiaries. Our objective is to lay out these considerations and to provide ways that they have been or can be addressed within the transition from traditional primary care to PCMH.