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Peebles PJ, Jensen EA, Herrick HM, Wildenhain PJ, Rumpel J, Moussa A, Singh N, Abou Mehrem A, Quek BH, Wagner M, Pouppirt NR, Glass KM, Tingay DG, Hodgson KA, O’Shea JE, Sawyer T, Brei BK, Jung P, Unrau J, Kim JH, Barry J, DeMeo S, Johnston LC, Nishisaki A, Foglia EE. Endotracheal Tube Size Adjustments Within Seven Days of Neonatal Intubation. Pediatrics 2024; 153:e2023062925. [PMID: 38469643 PMCID: PMC10979295 DOI: 10.1542/peds.2023-062925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations. METHODS Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups. RESULTS Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89). CONCLUSIONS For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized.
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Affiliation(s)
- Patrick J. Peebles
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Erik A. Jensen
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Jennifer Rumpel
- Univeristy of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ahmed Moussa
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Canada
| | - Neetu Singh
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | | | | | | | - David G. Tingay
- Neonatal Research, Murdoch Children’s Research Institute, Melbourne, Australia; Royal Children’s, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
| | | | | | | | | | - Philipp Jung
- University Hospital Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jennifer Unrau
- Alberta Children’s Hospital, University of Calgary, Alberta, Canada
| | - Jae H. Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James Barry
- University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Akira Nishisaki
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Dyess NF, Keels E, Myers P, French H, Reber K, LaTuga MS, Johnston LC, Scala M. Optimizing clinical care and training in the neonatal intensive care unit: the relationship between front line providers and physician trainees. J Perinatol 2023; 43:1513-1519. [PMID: 37580512 DOI: 10.1038/s41372-023-01749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/21/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023]
Abstract
Changes in neonatal intensive care unit (NICU) coverage models, restrictions in trainee work hours, and alterations to the training requirements of pediatric house staff have led to a rapid increase in utilization of front-line providers (FLPs) in the NICU. FLP describes a provider who cares for neonates and infants in the delivery room, nursery, and NICU, and includes nurse practitioners, physician assistants, and/or hospitalists. The increasing presence and responsibility of FLPs in the NICU have fundamentally changed the way patient care is provided as well as the learning environment for trainees. With these changes has come confusion over role clarity with resulting periodic conflict. While staffing changes have addressed a critical clinical gap, they have also highlighted areas for improvement amongst the teams of NICU providers. This paper describes the current landscape and summarizes improvement opportunities with a dynamic neonatal interprofessional provider team.
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Affiliation(s)
| | - Erin Keels
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick Myers
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Heather French
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Melissa Scala
- Stanford University School of Medicine, Palo Alto, CA, USA.
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Berlin KEK, Gray MM, Myers PJ, Scheurer JM, Robin B, McLean C, O'Reilly D, French H, Vasquez MM, Castera M, Redford KM, Edgar L, Johnston LC. A new era of assessment for neonatal-perinatal medicine trainees: milestones 2.0. J Perinatol 2023; 43:1506-1512. [PMID: 37095228 DOI: 10.1038/s41372-023-01683-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/14/2023] [Indexed: 04/26/2023]
Abstract
To optimize post-graduate competency-based assessment for medical trainees, the Accreditation Council for Graduate Medical Education initiated a sub-specialty-specific revision of the existing Milestones 1.0 assessment framework in 2016. This effort was intended to increase both the effectiveness and accessibility of the assessment tools by incorporating specialty-specific performance expectations for medical knowledge and patient care competencies; decreasing item length and complexity; minimizing inconsistencies across specialties through the development of common "harmonized" milestones; and providing supplemental materials, including examples of expected behaviors at each developmental level, suggested assessment strategies, and relevant resources. This manuscript describes the efforts of the Neonatal-Perinatal Medicine Milestones 2.0 Working Group, outlines the overall intent of Milestones 2.0, compares the novel Milestones to the original version, and details the materials contained in the novel supplemental guide. This new tool should enhance NPM fellow assessment and professional development while maintaining consistent performance expectations across specialties.
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Affiliation(s)
- Kathryn E K Berlin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Megan M Gray
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Patrick J Myers
- Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Johannah M Scheurer
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Beverley Robin
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
| | - Courtney McLean
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Deirdre O'Reilly
- Department of Pediatrics, University of Vermont, Burlington, VT, USA
| | - Heather French
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Margarita M Vasquez
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Mark Castera
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Laura Edgar
- Accreditation Council for Graduate Medical Education, Chicago, IL, USA
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
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Chang CL, Dyess NF, Johnston LC. Simulation in a blended learning curriculum for neonatology. Semin Perinatol 2023; 47:151824. [PMID: 37748941 DOI: 10.1016/j.semperi.2023.151824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Blended learning is a learner-centered educational method that combines online and traditional face-to-face educational strategies. Simulation is a commonly utilized platform for experiential learning and an ideal component of a blended learning curriculum. This section describes blended learning, including its strengths and limitations, educational frameworks, uses within health professions education, best practices, and challenges. Also included is a brief introduction to simulation-based education, along with theoretical and real-world examples of how simulation may be integrated into a blended learning curriculum. Examples of blended learning in Neonatal-Perinatal Medicine, specifically within the Neonatal Resuscitation Program, procedural skills training, and the National Neonatology Curriculum, are reviewed.
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Affiliation(s)
- Catherine L Chang
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Nicolle Fernández Dyess
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States.
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Johnston LC, Robin B. Introduction: Update on simulation in neonatology. Semin Perinatol 2023; 47:151829. [PMID: 37798171 DOI: 10.1016/j.semperi.2023.151829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Affiliation(s)
- Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, PO Box 208064, New Haven, CT 06520-8064, United States.
| | - Beverley Robin
- Department of Pediatrics, Rush University Medical Center, 1653 W. Congress Pkwy, Pavilion #350, Chicago, IL 60612, United States
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Forson-Dare Z, Du NR, Ocran A, Tiyyagura G, Bruno CJ, Johnston LC. How Good is Good Enough?: Current-Day Pediatric Residency Program Directors' Challenges in Assessing and Achieving Resident Procedural Competency. Acad Pediatr 2023; 23:473-482. [PMID: 36410602 DOI: 10.1016/j.acap.2022.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/03/2022] [Accepted: 11/09/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Significant gaps exist in the pediatric resident (PR) procedural experience. Graduating PRs are not achieving competency in the 13 ACGME recommended procedures. It is unclear why PR are not able to achieve competency, or how existing gaps may be addressed. METHODS We performed in-depth one-on-one semistructured interviews with 12 pediatric residency program directors (PPDs). The interviews were audio-recorded, and transcribed verbatim. Coding of the data using conventional content analysis led to generation of categories, which were validated through consensus development. RESULTS We identified 4 main categories, including (1) programs struggle to ensure adequate training in procedural skills for PRs, with various barriers reported; (2) programs develop individualized strategies to address challenges in procedural skills training, and multiple options are necessary; (3) PPDs face challenges defining procedural competency and standardizing expectations; and (4) expectations for PR procedural training may require modification based upon current practice environments. Solutions include simulation, procedural boot camps, and procedural/subspecialty electives. CONCLUSIONS Numerous methods to combat challenges in PR procedural training have been identified by participating PPDs, including simulation, tailoring electives, and developing institutional guidelines. However, accreditation bodies may need to update procedural expectations based on individual resident career goals and realities of current day practice.
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Affiliation(s)
- Zaneta Forson-Dare
- Department of Pediatrics (Z Forson-Dare, A Ocran, G Tiyyagura, J Bruno, and LC Johnston), Yale University School of Medicine, New Haven, Conn
| | - Nan R Du
- Department of Pediatrics (NR Du), Harvard University School of Medicine, Boston, Mass
| | - Amanda Ocran
- Department of Pediatrics (Z Forson-Dare, A Ocran, G Tiyyagura, J Bruno, and LC Johnston), Yale University School of Medicine, New Haven, Conn
| | - Gunjan Tiyyagura
- Department of Pediatrics (Z Forson-Dare, A Ocran, G Tiyyagura, J Bruno, and LC Johnston), Yale University School of Medicine, New Haven, Conn
| | - Christie J Bruno
- Department of Pediatrics (Z Forson-Dare, A Ocran, G Tiyyagura, J Bruno, and LC Johnston), Yale University School of Medicine, New Haven, Conn
| | - Lindsay C Johnston
- Department of Pediatrics (Z Forson-Dare, A Ocran, G Tiyyagura, J Bruno, and LC Johnston), Yale University School of Medicine, New Haven, Conn.
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Lee DT, Bruno CJ, Sharifi M, Shabanova V, Johnston LC. Assessing Barriers to Utilization of Premedication for Neonatal Intubation Based on the Theoretical Domains Framework. Am J Perinatol 2023. [PMID: 36646097 DOI: 10.1055/s-0042-1760449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study aimed to identify barriers and facilitators of premedication utilization for nonemergent neonatal intubations (NIs) in a level IV neonatal intensive care unit (NICU). STUDY DESIGN Between November 2018 and January 2019, multidisciplinary providers at a level IV NICU were invited to participate in an anonymous, electronic survey based on Theoretical Domains Framework to identify influences on utilization of evidence-based recommendations for NI premedication. RESULTS Of 186 surveys distributed, 84 (45%) providers responded. Most agreed with premedication use in the following domains: professional role/identity (86%), emotions (79%), skills (72%), optimism (71%), and memory, attention, and decision process (71%). Domains with less agreement include social influences (42%), knowledge (57%), intention (60%), belief about capabilities (63%), and behavior regulation (64%). Additional barriers include environmental context and resources, and beliefs about consequences. CONCLUSION Several factors influence premedication use for nonemergent NI and may serve as facilitators and/or barriers. Efforts to address barriers should incorporate a multidisciplinary approach to improve patient outcomes and decrease procedure-related pain. KEY POINTS · Premedication for NIs can optimize conditions and decrease rates of tracheal intubation adverse events but there is significant international and institutional variation for premedication use for NI.. · Guided by implementation science methods, the Theoretical Domains Framework was utilized to construct a novel assessment tool to determine potential barriers to and facilitators of the use of premedication for NI.. · Several factors influence premedication for nonemergent NI..
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Affiliation(s)
- Dianne T Lee
- Department of Pediatrics, Children's Mercy Kansas City Hospital, Kansas City, Missouri
| | - Christie J Bruno
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Mona Sharifi
- Department of Pediatrics, Center for Implementation Science, Yale University School of Medicine, New Haven, Connecticut
| | - Veronika Shabanova
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Boyd C, Myers P, Gray MM, Johnston LC. Illuminating the path towards inclusivity: strategies to improve workforce diversity in neonatal-perinatal medicine. J Perinatol 2023; 43:415-416. [PMID: 36624305 DOI: 10.1038/s41372-023-01599-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Affiliation(s)
- Cameron Boyd
- Department of Pediatrics, Northwestern University School of Medicine, Chicago, IL, USA
| | - Patrick Myers
- Department of Pediatrics, Northwestern University School of Medicine, Chicago, IL, USA
| | - Megan M Gray
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
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Gray MM, Dadiz R, Izatt S, Gillam-Krakauer M, Carbajal MM, Johnston LC, Payne A, Vasquez MM, Bonachea EM, Karpen H, Falck AJ, Chess PR, Huber M, French H. Comparison of knowledge acquisition and retention following traditional didactic vs. flipped classroom education utilizing a standardized national curriculum: a randomized controlled trial. J Perinatol 2022; 42:1512-1518. [PMID: 35660790 DOI: 10.1038/s41372-022-01423-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/10/2022] [Accepted: 05/26/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Measure the effectiveness of and preference for a standardized, national curriculum utilizing flipped classrooms (FC) in neonatal-perinatal medicine (NPM) fellowships. STUDY DESIGN Multicentered equivalence, cluster randomized controlled trial of NPM fellowship programs randomized to receive standardized physiology education as in-class lectures (traditional didactic, TD arm) or as pre-class online videos followed by in-class discussions (FC arm). Four multiple-choice question quizzes and three surveys were administered to measure knowledge acquisition, retention, and educational preferences. RESULTS 530 fellows from 61 NPM fellowships participated. Quiz performance was comparable between groups at all time points (p = NS, TD vs FC at 4 time points). Post intervention, more fellows in both groups preferred group discussions (pre/post FC 42% vs. 58%, P = 0.002; pre/post TD 43% vs. 60%, P = < 0.001). FC fellows were more likely to rate classroom effectiveness positively (FC/TD, 70% vs. 36%, P < 0.001). CONCLUSIONS FCs promote knowledge acquisition and retention equivalent to TD and FC modalities are preferred by fellows.
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Affiliation(s)
- Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way, Seattle, WA, 98105, USA
| | - Rita Dadiz
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 651, Rochester, 14642, Rochester, NY, USA
| | - Susan Izatt
- Department of Pediatrics, Duke University, DUMC Box 102509, Durham, NC, 27710, USA
| | - Maria Gillam-Krakauer
- Department of Pediatrics, Vanderbilt University Medical Center, 11112 Doctor's Office Tower, 2200 Children's Way, Nashville, TN, 37232, USA
| | - Melissa M Carbajal
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, W6104, Houston, TX, 77030, USA
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Allison Payne
- Department of Pediatrics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, RBC Suite 3100, Mailstop 6010, Cleveland, OH, 44106, USA
| | - Margarita M Vasquez
- Department of Pediatrics, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MSC 7812, San Antonio, TX, 78229, USA
| | - Elizabeth M Bonachea
- Department of Pediatrics, Ohio State University, 700 Children's Drive, FB 6th floor Neonatology, Columbus, OH, 43205, USA
| | - Heidi Karpen
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, 2105 Uppergate Drive NE, Rm 324, Atlanta, GA, 30033, USA
| | - Alison J Falck
- Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca 8th floor, Baltimore, MD, 21201, USA
| | - Patricia R Chess
- Departments of Pediatrics and Biomedical Engineering, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 651, Rochester, NY, 14642, USA
| | - Matthew Huber
- Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Heather French
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Johnston LC, Falck AJ, Vasquez MM, Dadiz R, French H, Izatt S, Bonachea E, Karpen HE, Carbajal MM, Payne A, Gillam-Krakauer M, Gray MM. Flipping the Teachers: Impact of a Standardized Physiology Curriculum on Neonatology Medical Educators. Am J Perinatol 2022. [PMID: 36041469 DOI: 10.1055/a-1933-4893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Academic physicians must teach elements in an Accreditation Council for Graduate Medical Education (ACGME)-mandated curriculum while balancing career development and clinical workload. Exploring educator perceptions on the learning environment and comparing two instructional methods (traditional didactics [TD] vs. flipped classroom [FC]) in one pediatric subspecialty may elucidate current challenges, barriers, and strategies to optimize learning and educator satisfaction. STUDY DESIGN A randomized trial comparing effectiveness and learner preference for FC versus TD physiology teaching was conducted in ACGME-accredited neonatal-perinatal medicine (NPM) fellowship programs in 2018 to 2019. Educator preferences were elicited through online surveys pre- and postintervention. Free-text comments were provided for questions exploring strengths, challenges, and opportunities in fellowship education. Statistical analysis included comparisons of demographics and pre-post-intervention educator responses between groups. Thematic analysis of text responses was conducted to identify common subthemes. RESULTS From 61 participating programs, 114 FC educators and 130 TD educators completed surveys. At baseline, all educators experienced professional satisfaction from teaching fellows, but noted challenges with time available to create and/or deliver educational content, limited content expertise amongst faculty, colleagues' limited enthusiasm toward educating fellows, and lack of perceived value of education by institutions given limited protected time or credit toward promotion. Postintervention, educators in both groups noted a preference to teach physiology using FC due to interactivity, learner enthusiasm, and learner-centeredness. FC educators had a 17% increase in preference to teach using FC (p = 0.001). Challenges with FC included ensuring adequate trainee preparation, protecting educational time, and providing educators with opportunities to develop facilitation skills. CONCLUSION Overall, NPM educators in a trial evaluating a standardized, peer-reviewed curriculum report professional satisfaction from teaching, but described logistical challenges with developing/delivering content. Educators preferred instruction using FC, but identified challenges with learner preparedness and ensuring adequate educator time and skill. Future efforts should be dedicated to addressing these barriers. KEY POINTS · Many challenges exist for educators teaching neonatal-perinatal medicine fellows, including time, support, and recognition.. · Many educators preferred using flipped classroom methodology with a standardized curriculum due to interactivity and learner-centeredness.. · Benefits of a standardized, peer-reviewed curriculum include reduced preparation time, adaptability of content, and learning environment enhancement..
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Affiliation(s)
- Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Alison J Falck
- Department of Pediatrics, University of California-San Francisco School of Medicine, San Francisco, California
| | - Margarita M Vasquez
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, Texas
| | - Rita Dadiz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Heather French
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Izatt
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Elizabeth Bonachea
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, NY
| | - Heidi E Karpen
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Allison Payne
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Maria Gillam-Krakauer
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Gray MM, Bruno C, French H, Myers P, Carbajal MM, Reber KM, Christou H, Karpen H, Johnston LC. Changes, Challenges, and Variations in Neonatal-Perinatal Medicine Fellowship: A View from the Program Directors. Am J Perinatol 2022. [PMID: 35554889 DOI: 10.1055/a-1850-3929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Neonatal-perinatal medicine (NPM) fellowship programs in the United States support >800 learners annually. Understanding variations in the programmatic structure, challenges, and needs is essential to optimize the educational environment and ensure the specialty's future. STUDY DESIGN NPM fellowship program directors (PDs) and associate program directors (APDs) were invited to complete an electronic survey on their program administration, recruitment, clinical training, assessment methods, scholarly program, and career pathways. Each participant identified individual programmatic strengths, challenges, opportunities, and threats to the field. RESULTS Representatives from 59 NPM fellowships provided data (response rate 59/96 = 61%). In total, 30% of PDs received less than the Accreditation Council for Graduate Medical Education -recommended protected time for administrative duties, and 44% of APDs received no protected time. Fellow clinical service assignments varied widely from 13 to 18 months and 90 to 175 call nights over 3 years. Recruitment practices varied across programs; 59% of respondents raised concerns over the pipeline of applicants. Conflicts between fellows and advanced practice providers were identified by 61% of responders. Programs varied in their scholarly offerings, with 44% of NPM fellowships interested in adding broader research opportunities. CONCLUSIONS NPM fellowship leaders identified a need for improved programmatic support, enhanced measures to assess competency, opportunities to strengthen scholarly programs, shared curricular resources, and strategies to balance education with clinical demands. PDs and APDs identified threats to the future of NPM training programs including the diminishing pipeline of applicants into neonatology, challenges with clinical exposure and competence, inadequate support for the educational mission, issues supporting high-quality scholarship, and fewer graduates pursuing physician-investigator pathways. National organizations and academic institutions should take action to address these challenges so that fellowships can optimally prepare graduates to meet their patients' needs. KEY POINTS · Numerous challenges exist for current program directors in NPM including balancing clinical work with scholarly activities, accurately assessing competency, optimizing the culture of the learning environment, and ensuring that fellows are adequately prepared for a range of postgraduate positions.. · Significant variation exists across NPM fellowship programs in clinical service/calls assigned over 3 years of fellowship training, as well as opportunities to pursue scholarly activities across a variety of areas.. · Challenges exist related to ensuring an adequate number of future applicants into the specialty, including those from backgrounds traditionally underrepresented in medicine, as well as those seeking to pursue careers as physician-investigators..
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Affiliation(s)
- Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Christie Bruno
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Heather French
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick Myers
- Department of Pediatrics, Northwestern School of Medicine, Chicago, Illinois
| | - Melissa M Carbajal
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Kristina M Reber
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Helen Christou
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi Karpen
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Trzaski JM, Kiefer AS, Myers P, Johnston LC. Essentials of Neonatal-Perinatal Medicine Fellowship: careers in Neonatal-Perinatal Medicine. J Perinatol 2022; 42:1135-1140. [PMID: 35094019 PMCID: PMC8799965 DOI: 10.1038/s41372-022-01315-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/13/2021] [Accepted: 01/04/2022] [Indexed: 11/25/2022]
Abstract
The clinical and academic landscape of Neonatal-Perinatal Medicine (NPM) is evolving. Career opportunities for neonatologists have been impacted by shifts in compensation and staffing needs in both academic and private settings. The workforce in NPM is changing with respect to age and gender. Recruiting candidates from backgrounds underrepresented in medicine is a priority. Developing flexible positions and ensuring equitable salaries is critically important. Professional niches including administration, education, research, and quality improvement provide many opportunities for scholarly pursuit. Challenges exist in recruiting, mentoring, funding, and retaining physician-scientists in NPM. Creative solutions are necessary to balance the needs of the NPM workforce with the growing numbers, locations, and complexity of patients. Addressing these challenges requires a multi-faceted approach including adapting educational curricula, supporting trainees in finding their niche, identifying novel ways to address work/life integration, and attracting candidates with both diverse backgrounds and academic interests.
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Affiliation(s)
- Jennifer M. Trzaski
- grid.63054.340000 0001 0860 4915Department of Pediatrics, Division of Neonatology, University of Connecticut School of Medicine/Connecticut Children’s, Hartford, CT USA
| | - Autumn S. Kiefer
- grid.268154.c0000 0001 2156 6140Department of Pediatrics, Division of Neonatology, West Virginia University School of Medicine, Morgantown, WV USA
| | - Patrick Myers
- grid.16753.360000 0001 2299 3507Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | | | - Lindsay C. Johnston
- grid.47100.320000000419368710Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT USA
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Gray MM, Dadiz R, Izatt S, Gillam-Krakauer M, Carbajal MM, Falck AJ, Bonachea EM, Johnston LC, Karpen H, Vasquez MM, Chess PR, French H. Value, Strengths, and Challenges of e-Learning Modules Paired with the Flipped Classroom for Graduate Medical Education: A Survey from the National Neonatology Curriculum. Am J Perinatol 2021; 38:e187-e192. [PMID: 32276279 DOI: 10.1055/s-0040-1709145] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. STUDY DESIGN This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. RESULTS Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30-60 vs. 0-15 minutes, p < 0.01). Faculty facilitators reported less preparation time before facilitating a FC compared with the time required for creating a new didactic lecture (median: 60 vs. 240 minutes, p < 0.01). Both fellows and faculty respondents preferred the FC approach to traditional didactics, with fellows showing a greater degree of preference than faculty (68 vs. 52%, respectively, p = 0.04). CONCLUSION Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.
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Affiliation(s)
- Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Rita Dadiz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Susan Izatt
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Maria Gillam-Krakauer
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa M Carbajal
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Alison J Falck
- Department of Pediatrics, University of Maryland, Baltimore, Maryland
| | | | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Heidi Karpen
- Department of Pediatrics, Emory Children's Pediatric Institute, Atlanta, Georgia
| | - Margarita M Vasquez
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, Texas
| | - Patricia R Chess
- Division of Pediatrics and Biomedical Engineering, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Heather French
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Sawyer T, Gray M, Chabra S, Johnston LC, Carbajal MM, Gillam-Krakauer M, Brady JM, French H. Milestone Level Changes From Residency to Fellowship: A Multicenter Cohort Study. J Grad Med Educ 2021; 13:377-384. [PMID: 34178263 PMCID: PMC8207935 DOI: 10.4300/jgme-d-20-00954.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/19/2020] [Accepted: 02/24/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND A vital element of the Next Accreditation System is measuring and reporting educational Milestones. Little is known about changes in Milestones levels during the transition from residency to fellowship training. OBJECTIVE Evaluate the Accreditation Council for Graduate Medical Education (ACGME) Milestones' ability to provide a linear trajectory of professional development from general pediatrics residency to neonatal-perinatal medicine (NPM) fellowship training. METHODS We identified 11 subcompetencies that were the same for general pediatrics residency and NPM fellowship. We then extracted the last residency Milestone level and the first fellowship Milestone level for each subcompetency from the ACGME's Accreditation Data System on 89 subjects who started fellowship training between 2014 and 2018 at 6 NPM fellowship programs. Mixed-effects models were used to examine the intra-individual changes in Milestone scores between residency and fellowship after adjusting for the effects of the individual programs. RESULTS A total of 1905 subcompetency Milestone levels were analyzed. The average first fellowship Milestone levels were significantly lower than the last residency Milestone levels (residency, mean 3.99 [SD = 0.48] vs fellowship 2.51 [SD = 0.56]; P < .001). Milestone levels decreased by an average of -1.49 (SD = 0.65) from the last residency to the first fellowship evaluation. Significant differences in Milestone levels were seen in both context-dependent subcompetencies (patient care and medical knowledge) and context-independent subcompetencies (professionalism). CONCLUSIONS Contrary to providing a linear trajectory of professional development, we found that Milestone levels were reset when trainees transitioned from general pediatrics residency to NPM fellowship.
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Affiliation(s)
- Taylor Sawyer
- Taylor Sawyer, DO, MEd, is Associate Fellowship Director, Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine
| | - Megan Gray
- Megan Gray, MD, is Fellowship Director, Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine
| | - Shilpi Chabra
- Shilpi Chabra, MD, is Associate Professor of Pediatrics, Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine
| | - Lindsay C. Johnston
- Lindsay C. Johnston, MD, MEd, is Fellowship Director, Department of Pediatrics, Division of Neonatology, Yale University School of Medicine
| | - Melissa M. Carbajal
- Melissa M. Carbajal, MD, is Fellowship Director, Department of Pediatrics, Division of Neonatology, Baylor College of Medicine/Texas Children's Hospital
| | - Maria Gillam-Krakauer
- Maria Gillam-Krakauer, MD, MEd, is Assistant Professor of Pediatrics, Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center
| | - Jennifer M. Brady
- Jennifer M. Brady, MD, is Assistant Professor of Pediatrics, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Heather French
- Heather French, MD, MSEd, is Fellowship Director, Department of Pediatrics, Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania
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Herrick HM, Glass KM, Johnston LC, Singh N, Shults J, Ades A, Nadkarni V, Nishisaki A, Foglia EE. Comparison of Neonatal Intubation Practice and Outcomes between the Neonatal Intensive Care Unit and Delivery Room. Neonatology 2020; 117:65-72. [PMID: 31563910 PMCID: PMC7098841 DOI: 10.1159/000502611] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Characteristics of neonatal tracheal intubations (TI) may vary between the neonatal intensive care unit (NICU) and delivery room (DR). The impact of the setting on TI outcomes is not well characterized. OBJECTIVE The aim of this study was to define variation in neonatal TI practice between settings, and identify the association between setting and TI success and safety outcomes. DESIGN This was a retrospective cohort study of TIs in the National Emergency Airway Registry for Neonates from October 2014 to September 2017. The setting (NICU vs. DR) was the exposure of interest. The outcomes were first attempt success, course success, success within 4 attempts, adverse TI-associated events, severe desaturation, and bradycardia. We compared TI characteristics and outcomes between settings in univariable analysis. Factors significant in univariable analysis (p < 0.1) were included in a logistic regression model, with adjustment for clustering by center, to identify the independent impact of the setting on TI outcomes. RESULTS There were 3,145 TI encounters (2279 NICU, 866 DR) in 9 centers. Almost all baseline characteristics significantly varied between settings. First attempt success rates were 48% (NICU) and 46% (DR). In multivariable analysis, the setting was not associated with first attempt success. DR was associated with a higher adjusted OR (aOR) of success within 4 attempts (1.48, 95% CI 1.06-2.08) and a lower aOR for bradycardia (0.43, 95% CI 0.26-0.71). CONCLUSION Significant differences in patient, provider, and practice characteristics exist between NICU and DR TIs. There is substantial room for improvement in first attempt success rates. These results suggest interventions to improve safety and success need to be targeted to the distinct setting.
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Affiliation(s)
- Heidi Meredith Herrick
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,
| | - Kristen M Glass
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State Health Children's Hospital and Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Lindsay C Johnston
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Neetu Singh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Justine Shults
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, Quek BH, Johnston LC, Barry J, Zenge J, Moussa A, Kim JH, DeMeo SD, Napolitano N, Nadkarni V, Nishisaki A. Neonatal Intubation Practice and Outcomes: An International Registry Study. Pediatrics 2019; 143:peds.2018-0902. [PMID: 30538147 PMCID: PMC6317557 DOI: 10.1542/peds.2018-0902] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. METHODS We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression. RESULTS We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57). CONCLUSIONS We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Taylor Sawyer
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Kristen M. Glass
- Penn State Health Children’s Hospital and Penn State College of Medicine, Hershey, Pennsylvania
| | - Neetu Singh
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany
| | - Bin Huey Quek
- KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Lindsay C. Johnston
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - James Barry
- Department of Pediatrics, Section of Neonatology, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jeanne Zenge
- Department of Pediatrics, Section of Neonatology, School of Medicine, University of Colorado, Aurora, Colorado
| | - Ahmed Moussa
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Jae H. Kim
- Division of Neonatology, Department of Pediatrics, University of California, San Diego and Rady Children’s Hospital of San Diego, San Diego, California
| | | | - Natalie Napolitano
- Departments of Nursing, Respiratory Care and Neurodiagnostic Services and
| | - Vinay Nadkarni
- Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Johnston LC, Rintoul NE, Ades AM. Introduction: Update on neonatal extracorporeal membrane oxygenation. Semin Perinatol 2018; 42:65-67. [PMID: 29291939 DOI: 10.1053/j.semperi.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Lindsay C Johnston
- Division of Neonatal-Perinatal Medicine Yale School of Medicine, 430 Congress Avenue New Haven, CT 06520-8064.
| | - Natalie E Rintoul
- Division of Neonatology, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104
| | - Anne M Ades
- Division of Neonatology, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104
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Affiliation(s)
- Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064.
| | - Stephanie N Sudikoff
- SYN:APSE Center for Learning, Transformation, and Innovation, Yale-New Haven Health System, New Haven, CT; Department of Pediatrics, Pediatric Critical Care, Yale School of Medicine, New Haven, CT
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Johnston LC, Chen R, Whitfill TM, Bruno CJ, Levit OL, Auerbach MA. Do you see what I see? A randomised pilot study to evaluate the effectiveness and efficiency of simulation-based training with videolaryngoscopy for neonatal intubation. BMJ STEL 2015; 1:12-18. [DOI: 10.1136/bmjstel-2015-000031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/30/2015] [Indexed: 11/04/2022]
Abstract
IntroductionDirect laryngoscopy (DL) and airway intubation are critical for neonatal resuscitation. A challenge in teaching DL is that the instructor cannot assess the learners’ airway view. Videolaryngoscopy (VL), which allows display of a patient's airway on a monitor, enables the instructor to view the airway during the procedure. This pilot study compared deliberate practice using either VL with instruction (I-VL) or traditional DL. We hypothesised that I-VL would improve the efficiency and effectiveness of neonatal intubation (NI) training.MethodsParticipants (students, paediatric interns and neonatal fellows) were randomised to I-VL or DL. Baseline technical skills were assessed using a skills checklist and global skills assessment. Following educational sessions, deliberate practice was performed on mannequins using the Storz C-MAC. With I-VL, the instructor could guide training using a real-time airway monitor view. With DL, feedback was based solely on technique or direct visual confirmation, but the instructor and learner views were not concurrent. During summative assessment, procedural skills checklists were used to evaluate intubation ability on a neonatal airway trainer. The duration of attempts was recorded, and recorded airway views were blindly reviewed for airway grade. ‘Effectiveness’ reflected achievement of the minimum passing score (MPS). ‘Efficiency’ was the duration of training for learners achieving the MPS.Results58 learners were randomised. Baseline demographics were similar. All participants had a significant improvement in knowledge, skills and comfort/confidence following training. There were no significant differences between randomised groups in efficiency or effectiveness, but trends towards improvement in each were noted. Fellows were more likely to achieve ‘competency’ postinstruction compared to non-fellows (p<0.001).ConclusionsThis educational intervention to teach NI increased the learner's knowledge, technical skills and confidence in procedural performance in both groups. I-VL did not improve training effectiveness. The small sample size and participant diversity may have limited findings, and future work is indicated.
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Johnston LC, Auerbach M, Kappus L, Emerson B, Zigmont J, Sudikoff SN. Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy. Teach Learn Med 2014; 26:285-291. [PMID: 25010241 DOI: 10.1080/10401334.2014.910462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). PURPOSES This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. METHODS Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. RESULTS Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. CONCLUSIONS A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.
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Affiliation(s)
- Lindsay C Johnston
- a Neonatal-Perinatal Medicine, Yale University School of Medicine , New Haven , Connecticut , USA
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Abstract
Every delivery is a multidisciplinary event, involving nursing, obstetricians, anesthesiologists, and pediatricians. Patients are often in labor across multiple provider shifts, necessitating numerous handoffs between teams. Each handoff provides an opportunity for errors. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of complications result from team, rather than individual, failures. In 2004, a Sentinel Alert issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization's culture and communication failures. It was recommended that hospitals implement teamwork training programs in an effort to improve outcomes. Instituting a multidisciplinary teamwork training program that uses simulation offers a risk-free environment to practice skills, including communication, role clarification, and mutual support. This experience should improve patient safety and outcomes, as well as enhance employee morale.
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Affiliation(s)
- Shad Deering
- Division of Maternal Fetal Medicine, Andersen Simulation Center, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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Jones CA, Johnston LC, Jackson MJ, Smith LA, van Scharrenburg G, Rose S, Jenner PG, McCreary AC. An in vivo pharmacological evaluation of pardoprunox (SLV308)--a novel combined dopamine D(2)/D(3) receptor partial agonist and 5-HT(1A) receptor agonist with efficacy in experimental models of Parkinson's disease. Eur Neuropsychopharmacol 2010; 20:582-93. [PMID: 20434890 DOI: 10.1016/j.euroneuro.2010.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 02/05/2010] [Accepted: 03/10/2010] [Indexed: 11/17/2022]
Abstract
Partial D(2/3) dopamine (DA) receptor agonists provide a novel approach to the treatment of the motor symptoms of Parkinson's disease (PD) that may avoid common dopaminergic side-effects, including dyskinesia and psychosis. The present study focussed on the in vivo pharmacological and therapeutic characterisation of the novel D(2/3) receptor partial agonist and full 5-HT(1A) receptor agonist pardoprunox (SLV308; 7-[4-methyl-1-piperazinyl]-2(3H)-benzoxazolone monochloride). Pardoprunox induced contralateral turning behaviour in rats with unilateral 6-hydroxydopamine-induced lesions of the substantia nigra pars compacta (SNpc) (MED=0.03mg/kg; po). In 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated common marmosets, pardoprunox dose-dependently increased locomotor activity (MED=0.03mg/kg; po) and decreased motor disability (MED=0.03mg/kg; po). The effects of pardoprunox were reversed by the D(2) antagonist sulpiride. In contrast pardoprunox attenuated novelty-induced locomotor activity (MED=0.01mg/kg; po), (+)-amphetamine-induced hyperlocomotion (MED=0.3mg/kg; po) and apomorphine-induced climbing (MED=0.6mg/kg; po) in rodents. Pardoprunox also induced 5-HT(1A) receptor-mediated behaviours, including flat body posture and lower lip retraction (MED=0.3mg/kg; po) and these were reversed by the 5-HT(1A) receptor antagonist WAY100635. Collectively, these findings demonstrate that pardoprunox possesses dopamine D2/3 partial agonist effects, 5-HT1A agonist effects and reduces parkinsonism in animal models. functional DA D(2) receptor partial agonist activity and is effective in experimental models predictive of efficacy in PD. The presence of functional 5-HT(1A) agonist activity might confer anti-dyskinetic activity and have effects that control neuropsychiatric components of PD.
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Affiliation(s)
- C A Jones
- Abbott Pharmaceuticals B.V., Weesp, The Netherlands (formerly Solvay Pharmaceuticals B.V.)
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Abstract
Clinical trials demonstrated decreasing rates of bronchopulmonary dysplasia in preterm infants with hypoxic respiratory failure treated with inhaled nitric oxide (iNO). However, the molecular and biochemical effects of iNO on developing human fetal lungs remain vastly unknown. By using a well-characterized model of human fetal alveolar type II cells, we assessed the effects of iNO and hyperoxia, independently and concurrently, on NO-cGMP signaling pathway and differentiation. Exposure to iNO increased cGMP levels by 40-fold after 3 d and by 8-fold after 5 d despite constant expression of phosphodiesterase-5 (PDE5). The levels of cGMP declined significantly on exposure to iNO and hyperoxia at 3 and 5 d, although expression of soluble guanylyl cyclase (sGC) was sustained. Surfactant proteins B and C (SP-B, SP-C) and thyroid transcription factor (TTF)-1 mRNA levels increased in cells exposed to iNO in normoxia but not on exposure to iNO plus hyperoxia. Collectively, these data indicate an increase in type II cell markers when undifferentiated lung epithelial cells are exposed to iNO in room air. However, hyperoxia overrides these potentially beneficial effects of iNO despite sustained expression of sGC.
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Affiliation(s)
- Lindsay C Johnston
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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Johnston LC, Feldman HM, Paradise JL, Bernard BS, Colborn DK, Casselbrant ML, Janosky JE. Tympanic membrane abnormalities and hearing levels at the ages of 5 and 6 years in relation to persistent otitis media and tympanostomy tube insertion in the first 3 years of life: a prospective study incorporating a randomized clinical trial. Pediatrics 2004; 114:e58-67. [PMID: 15231974 DOI: 10.1542/peds.114.1.e58] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE One current practice guideline recommends myringotomy with tympanostomy tube insertion (M&T) for young children in whom middle-ear effusion (MEE) has persisted for 3 months, and another recommends the procedure after MEE has persisted for 4 to 6 months provided that a bilateral hearing loss of > or=20 dB is present. Sequelae of M&T are not uncommon, but the extent to which these sequelae are attributable to M&T itself or to the middle-ear disease that prompted the procedure or to both has not been clear. Our objective in the present study was to examine the prevalence of various tympanic membrane (TM) abnormalities in otherwise healthy children at the age of 5 years and hearing levels at the age of 6 years in relation to persistent MEE and M&T in the children's first 3 years of life. METHODS In a prospective study of child development in relation to early-life otitis media, we randomly assigned 429 children who met specified criteria regarding the persistence of MEE in their first 3 years of life to undergo M&T either promptly (the "early-treatment" group) or after a defined extended period if MEE remained present (the "late-treatment" group). We also followed a representative sample of 241 children who ranged from having no MEE to having MEE whose cumulative duration fell just short of meeting randomization criteria for the clinical trial (the "nontrial" group). Most of the children in each group underwent both otomicroscopic examination at the age of 5 years and audiometric testing at the age of 6 years, at times when they were free of MEE. Among these children, M&T had been performed in 82.3% of those in the early-treatment group, 38.1% of those in the late-treatment group, and 3.0% of those in the nontrial group. RESULTS At the age of 5 years, we found 1 or more types of TM abnormality in 1 or both ears in 70.7%, 42.5%, and 9.5% of the children in the early-treatment, late-treatment, and nontrial groups, respectively. Within the 3 groups, however, among children who received tubes, the proportions who had an abnormality of some type were similar, namely, 82.6%, 80.4%, and 83.3%, respectively. The corresponding proportions among children who had not received tubes were 15.4%, 19.3%, and 7.2%, respectively. Segmental atrophy and tympanosclerosis were the most common abnormalities found. At the age of 6 years, mean pure-tone average audiometric thresholds in the early-treatment, late-treatment, and nontrial groups, respectively, were 6.18 dB, 5.49 dB, and 4.63 dB in left ears and 6.17 dB, 6.02 dB, and 4.32 dB in right ears. The thresholds in the early- and late-treatment groups did not differ significantly, but the thresholds in the early- and late-treatment groups were each significantly higher than in the nontrial group. Within the early- and late-treatment groups, we found no significant relation between hearing levels and the presence or type of TM abnormalities. CONCLUSION In otherwise healthy children who have persistent MEE during their first 3 years of life, ready resort to M&T results in far more TM abnormalities at age 5 than does selective management in which most children do not receive the procedure. With these differing approaches, however, hearing levels at age 6 do not differ. Regardless of whether children with persistent early-life MEE receive M&T, they have more TM abnormalities at age 5 and negligibly poorer hearing at age 6 than do children who had less or no otitis media. Longer term otologic and audiologic outcomes of persistent early-life MEE and of M&T remain to be determined. In view of 1) the present findings and the remaining uncertainties concerning sequelae, 2) the fact that M&T involves certain immediate risks--albeit minimal--and substantial cost, and 3) previously reported findings in the study's randomized clinical trial that show no developmental advantage at ages 3 and 4 years accruing from children's having received prompt M&T, a prolonged period of watchful waiting seems desirable in otherwise healthy children who are younger than 3 years and have persistent, asymptomatic MEE that is not complicated by sensorineural or severe conductive hearing loss, balance dysfunction, or severe TM retraction.
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Affiliation(s)
- Lindsay C Johnston
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Junnarkar SP, Reid J, Johnston LC, Lee B, Hannon RJ, Soong CV. Endovascular repair for acute symptomatic and ruptured abdominal aortic aneurysms. Ulster Med J 2001; 70:51-3. [PMID: 11428326 PMCID: PMC2449213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S P Junnarkar
- Vascular Surgery Unit, Tower Block, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB
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Abstract
A primary aortocaval fistula is present in less than 1% of all abdominal aortic aneurysms. Until recently, surgical repair was the only method of treatment and was associated with a high incidence of morbidity and mortality. With the rapid development of aortic stent-graft technique, endovascular stent-graft repair may offer an alternative to the management of this often fatal condition. We report a case of an aortoiliac aneurysm with an aortocaval fistula successfully treated with endovascular stent-grafting. The unique hemodynamic changes, technical problems, and complications associated with this case are discussed, and the literature is reviewed.
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Affiliation(s)
- L L Lau
- Vascular Surgery Unit, and the Department of Radiology, Belfast City Hospital, Northern Ireland.
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Callum KG, Whimster F, Dyet JF, Gaines PA, Gillespie I, Johnston LC, Ruttley M. The report of the National Confidential Enquiry into Perioperative Deaths for Interventional Vascular Radiology. Cardiovasc Intervent Radiol 2001; 24:2-24. [PMID: 11178708 DOI: 10.1007/s002700001778] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Makar R, Reid J, Pherwani AD, Johnston LC, Hannon RJ, Lee B, Soong CV. Aorto-enteric fistula following endovascular repair of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2000; 20:588-90. [PMID: 11136600 DOI: 10.1053/ejvs.2000.1247] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- R Makar
- Vascular Surgery Unit, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, Northern Ireland
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Johnston LC, Larkin KA, Curry RC. Day-case arteriography. Ulster Med J 1993; 62:29-31. [PMID: 8516971 PMCID: PMC2449031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Outpatient femoral arteriography has been carried out in 100 consecutive patients presenting with evidence of peripheral vascular disease. Patients have been observed for seven hours in an observation ward bed. No bleeding or other complications have been encountered. The cost-saving to the hospital is approximately 60.00 pounds per case. More importantly, the service to patients has been improved, with less chance of last minute cancellation due to unavailability of a surgical bed.
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Johnston LC. Yet more, yet older snakes. JAMA 1986; 255:2445-6. [PMID: 3517391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Very heavy social drinkers demonstrated less slowing of their heart rate than controls while exhaling after a maximal inhalation. While this suggests defective autonomic control of the heart, clarification of the mechanism and significance of this reflex and its impairment must await sophisticated study.
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Abstract
A group of patients with borderline or labile hypertension were prospectively recruited and asked to take a deep breath while lying supine and being monitored by electrocardiography. Their attenuated heart rate responses were sharply abnormal, demonstrating an excessively rapid rate throughout but without quickening on inspiration nor slowing with expiration. It is suggested that this further demonstrates inadequate autonomic control, sympathetic and parasympathetic, of the heart in labile hypertension and even at a moment when the patient's blood pressure is normal.
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Johnston LC. Current treatment of essential hypertension. IMJ Ill Med J 1977; 151:25-8. [PMID: 12102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Terminally ill cancer patients die at different rates and some of this variance is due to psychosocial differences. In order to discover this variance we developed the Survival Quotient, an index of relative longevity which is applicable across different tumor sites with widely differing life expectancies. The Quotient is based on the difference between Observed Survival, i.e., how long a patient lived from diagnosis to death, and Expected Survival, or how long he was expected to live when compared to a large series of deceased patients with the same tumor site. To obtain an estimate of Expected Survival for six cancer sites (lung, breast, stomach, colon, cervix, lymphoma), six detailed multiple regressions were done. To illustrate the procedure, only one site (lung) is used along with case samples. The Survival Quotient can be useful in research where it is necessary to assess the velocity of dying while controlling for biological differences and similarities.
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Johnston LC, Santos DE, Gantt C. The antihypertensive properties of furosemide on chronic oral administration. J Clin Pharmacol J New Drugs 1970; 10:121-5. [PMID: 4906540 DOI: 10.1177/009127007001000207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Johnston LC, Grieble HG. Treatment of arterial hypertensive disease with diuretics. V. Spironolactone, an aldosterone antagonist. Arch Intern Med 1967; 119:225-31. [PMID: 6020067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Remenchik AP, Johnston LC. Potassium depletion produced by administration of chlorthalidone to nonedematous patients with arterial hypertensin. Am J Med Sci 1966; 252:171-6. [PMID: 5924015 DOI: 10.1097/00000441-196608000-00006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Johnston LC, Grieble HG, Schoenberger JA, Gantt CL. Treatment of arterial hypertensive disease with diuretics. IV. Effects of long-term high sodium intake on the response to chlorthalidone. Am J Med Sci 1965; 250:680-7. [PMID: 5321241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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