Estimation of the causal effect of sex on neonatal intensive care unit outcomes among very low birth weight infants

OBJECTIVE

Estimate the causal effect of sex on outcomes in the neonatal intensive care unit (NICU) among very low birth weight (VLBW) infants.

STUDY DESIGN

Retrospective cohort study using Vermont Oxford Network data to compare NICU outcomes for VLBW males versus females. Odds ratios (OR) for outcomes that differed significantly by sex were computed using standard unweighted analysis and inverse probability weighted (IPW) analysis to correct for selection bias.

RESULTS

Using standard analysis, males were significantly more likely to die before discharge and experience six other adverse outcomes. From IPW analysis, male sex caused a 56% increase in the odds of death before discharge (OR = 1.56, 95% confidence interval: 1.18-1.94). Standard unweighted results were significantly biased towards increased risk of adverse outcomes for males (p = 0.005) compared to IPW results for which three outcomes were no longer significantly associated with male sex.

CONCLUSION

Standard statistical methods generally overestimate the casual effect of sex among VLBW infants.

Comparing nasal suction devices in children with bronchiolitis: A pilot randomized control trial

BACKGROUND/OBJECTIVES

Bronchiolitis is the most common cause of lower respiratory tract infections that lead to hospitalizations in infants and young children.

METHODS

In this randomized controlled pilot study, we compared two separate nasal suction devices, namely the over counter device by the brand name of NoseFrida and the standard hospital device NeoSucker, in hospitalized children with bronchiolitis to assess equivalence of length of stay within a ± 5-h equivalence margin and to compare readmission rates and associated complications. Additionally, parental satisfaction for the NoseFrida device was measured with a six question (5-point Likert scale) survey.

RESULTS

There were 20 patients randomized to the NeoSucker group and 24 randomized to the NoseFrida group. The mean length of stay for the NoseFrida group was 33.5 ± 25.4 h compared to 31.0 ± 15.6 h in the NeoSucker group, which did not establish equivalence within the ±5-h equivalence margin (p = 0.352). Parents were generally satisfied with the NoseFrida. Patients treated with the two devices had similar frequencies of deep suctioning and readmission within 48 h.

CONCLUSIONS

Although the mean length of stay was comparable for bronchiolitis patients treated with the NoseFrida and NeoSucker, the relatively small sample size and large amount of variability precluded demonstrating equivalence. Since this was a pilot, further studies are needed to evaluate the recommendation for the use of such devices in both the hospital setting and in the outpatient management of bronchiolitis.

Variability in Diagnosis and Management of Hypoglycemia in Neonatal Intensive Care Unit

OBJECTIVE

 Hypoglycemia, the most common metabolic derangement in the newborn period remains a contentious issue, not only due to various numerical definitions, but also due to limited therapeutical options which either lack evidence to support their efficacy or are increasingly recognized to lead to adverse reactions in this population. This study aimed to investigate neonatologists' current attitudes in diagnosing and managing transient and persistent hypoglycemia in newborns admitted to the Neonatal Intensive Care Unit (NICU).

METHODS

 A web-based electronic survey which included 34 questions and a clinical vignette was sent to U.S. neonatologists.

RESULTS

 There were 246 survey responses with most respondents using local protocols to manage this condition. The median glucose value used as the numerical definition of hypoglycemia in first 48 hours of life (HOL) for symptomatic and asymptomatic term infants and preterm infants was 45 mg/dL (2.5 mmol/L; 25-60 mg/dL; 1.4-3.3 mmol/L), while after 48 HOL the median value was 50 mg/dL (2.8 mmol/L; 30-70 mg/dL; 1.7-3.9 mmol/L). There were various approaches used to manage transient and persistent hypoglycemia that included dextrose gel, increasing caloric content of the feeds using milk fortifiers, using continuous feedings, formula or complex carbohydrates, and use of various medications such as diazoxide, glucocorticoids, and glucagon.

CONCLUSION

 There is still large variability in current practices related to hypoglycemia. Further research is needed not only to provide evidence to support the values used as a numerical definition for hypoglycemia, but also on the efficacy of current strategies used to manage this condition.

KEY POINTS

· Numerical definition of glucose remains variable.. · Strategies managing transient and persistent hypoglycemia are diverse.. · There is a need for further research to investigate efficacy of various treatment options..

Perioperative and Long-Term Outcomes in Infants Undergoing a Tracheostomy from a Neonatal Intensive Care Unit

OBJECTIVE

The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy.

METHODS

This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy.

RESULTS

One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44-8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy.

CONCLUSION

Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1945-1954, 2024.

Oxygen saturation index: an adjunct for oxygenation index in congenital diaphragmatic hernia

OBJECTIVE

Our objective was to investigate the correlation of Oxygen Saturation Index (OSI) with Oxygenation Index (OI) and determine OSImax values that could predict need for ECMO and death in Congenital Diaphragmatic Hernia (CDH).

STUDY DESIGN

This is a retrospective cohort study of infants with CDH admitted to a tertiary level VI NICU. Pearson's correlation coefficient and simple linear regression analysis were used to investigate the OSI: OI correlation, and logistic regression analysis to investigate OSImax values that predicted need for ECMO and death.

RESULTS

Among the 180 infants, OSImax value of >13 at 6 h of life (HOL) best predicted need for ECMO and death. There was a strong correlation between OSI: OI paired values (r = 0.876, p < 0.001). The linear regression equation was OI = -2.4 + 2.4(OSI).

CONCLUSION

OSI could be used as a valuable adjunct to OI in the clinical management of newborn infants with CDH.

Factors associated with enteral autonomy after reanastomosis in infants with intestinal failure and ostomy: A descriptive cohort study

BACKGROUND

To determine variables associated with outcomes in infants with intestinal failure (IF) and ostomy following reanastomosis (RA).

METHODS

A single-center, descriptive cohort study of 120 infants with IF and a stoma from January 2011 to December 2020 with subsequent RA during initial hospitalization. The primary outcome was achievement of enteral autonomy (EA) following RA. Other outcomes were duration of hospital stay, and mortality. Penalized logistic regression and linear regression were used for data analysis.

RESULTS

The median gestational age was 26 weeks, and the median birth weight was 890 g. Three infants died. The median duration between ostomy creation and RA was 80 days (interquartile range; 62.5, 100.5). For each additional day of discontinuity, the odds of EA decreased by 2% (odds ratio [OR] = 0.980; 95% confidence interval [CI]: 0.962, 0.999; P = 0.038), and death increased by 4.2% (OR = 1.042; 95% CI: 1.010, 1.075; P = 0.009). For each additional mL/kg/day of enteral feeds at RA, the odds of EA increased by 7.5% (OR = 1.075; 95% CI: 1.027, 1.126, P = 0.002) and duration of hospital stay decreased by 0.35 days (slope coefficient = -0.351; 95% CI: -0.540, -0.163; P < 0.001).

CONCLUSION

Shorter duration of intestinal discontinuity and enteral nutrition before RA could positively influence EA and duration of stay in infants with IF and ostomy following RA.

Investigation of social support as a mediator of the relationship between physical and psychological health among hospitalised patients

AIM

To investigate the self-reported levels of social support from friends and family and from nurses as mediators of the relationship between self-rated physical and psychological condition in hospitalised patients.

DESIGN

Cross-sectional study of adult inpatients at a large tertiary-care hospital in the northeast United States.

METHODS

Multiple mediation analysis of survey data.

RESULTS

In surveys received from 324 inpatients, one fourth of the variation in patients' self-rated psychological condition was explained by self-rated physical condition. Social support from family and friends mediated a significant proportion (11.0%) of the relationship between self-rated physical and psychological condition, however social support from nurses did not.

CONCLUSION

Social support from family and friends can positively influence the psychological health of inpatients, but nurses are not an adequate replacement for the social support provided by family and friends.

IMPLICATIONS FOR NURSING

Although nurses cannot replace the social support provided by family and friends, the assessment of social isolation and care planning of interventions to support patients is a fundamental nursing role. Technology to connect patients with friends and family should be used to mitigate isolation for hospitalised patients unable to receive in-person visits from loved ones.

IMPACT

The influence of social support from family and friends and nurses was addressed. The study found social support from family and friends, but not nurses, to influence the relationship between physical and psychological ratings. This finding has implications for the role of nurses in the hospital setting.

REPORTING METHOD

Strengthening the Reporting of Observational Studies in Epidemiology guidelines were followed.

A recorder/time coach decreases time errors during neonatal resuscitation: A randomized, simulation-based clinical trial

Aim

To evaluate the effects of a hands-off recorder/time coach versus an additional hands-on healthcare provider on Neonatal Resuscitation Program (NRP) algorithm compliance and team member workload in neonatal resuscitations.

Methods

Two interventions were studied using a 2 × 2 factorial design: an additional hands-on team member and the presence of a designated, hands-off recorder/time coach. The recorder/time coach documented interventions and delivered pre-specified prompts at defined points during the resuscitation. The primary outcome was cumulative time error. Secondary outcomes were time to first dose of IV epinephrine, overall team performance as assessed by the Neonatal Resuscitation Performance Evaluation (NRPE) score, and workload assessed by the NASA Task Load Index (NASA TLX).

Results

64 teams were studied. Teams with a recorder had a significantly lower cumulative time error compared to teams without a recorder (p < 0.001). An additional hands-on team member did not change cumulative time error. There was no difference in time to first dose of IV epinephrine or NRPE score in these comparisons. Ad-hoc analysis did reveal a significant increase in time to IV epinephrine in teams with the minimum of four total members (p = 0.025). A recorder/time coach increased team leader NASA TLX overall workload score (p = 0.047), but an additional hands-on team member did not.

Conclusion

A designated, hands-off recorder/time coach improved compliance by decreasing cumulative time error in teams performing complex simulated neonatal resuscitations.

Comparison of Platelet Mass Index to Platelet Count as Transfusion Trigger in Neonatal Extracorporeal Membrane Oxygenation

BACKGROUND

Platelet transfusions are routinely administered to neonates in intensive care units when there are concerns of bleeding, including high-risk situations like Extracorporeal Membrane Oxygenation (ECMO). Most platelets in ICUs are transfused prophylactically for thrombocytopenia based solely on the platelet count. Platelet Mass Index (PMI) has been proposed as an alternative to platelet count (PC) as a transfusion trigger. The objective of this study was to determine the relationship between PMI and platelet-specific maximal clot firmness (PMCF) in Rotational thromboelastometry (ROTEM), which gives an indication of platelet contribution to clot firmness and to investigate whether PMI may be a better choice as a trigger for platelet transfusions than PC.

METHODS

Retrospective review of medical records of neonates with congenital heart disease placed on ECMO support in the cardiovascular intensive care unit (CVICU) from 2015 to 2018 was conducted. Platelet count (PC), platelet mean volume (PMV), ROTEM parameters along with demographic data including gestation age, birth weight, gender and survival were collected. Mixed effects linear models with a first order autoregressive covariance structure were used to assess the associations of PMI, PC, and MPV against PMCF. In addition, generalized estimating equations with a first order auto-regressive covariance structure were used to compare odds of transfusion using PC versus PMI triggers.

RESULTS

A total of 92 tests on consecutive days were obtained for 12 ECMO patients (5 male, GA = 38.1 ± 1.6 weeks, BW = 3.1 ± 0.4 kgs, mean ± SD). A variation of 40.1% in PMCF was explained by platelet count (p < 0.001) while 38.5% of the variation in PMCF was explained by PMI (p < 0.001). If the platelet transfusion trigger was PC < 100 x 103 platelets/µL vs. PMI < 800. Using the PC trigger yielded significantly higher odds of transfusion compared to the PMI trigger (odds ratio = 1.31, 95% confidence interval: 1.18 - 1.45, p < 0.001).

CONCLUSIONS

While our study failed to demonstrate a superior correlation of PMI with PMCF than PC, our study did reveal that using PMI as transfusion trigger would result in significantly less platelet transfusions, when compared with the current practice of using PC as a trigger.

Inotropic score and vasoactive inotropic score as predictors of outcomes in congenital diaphragmatic hernia: A single center retrospective study

BACKGROUND

Neonates with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac dysfunction. These neonates frequently require vasoactive support and are at high risk for mortality and morbidity, including prolonged ventilator support, need for extracorporeal membrane oxygenation (ECMO), prolonged length of stay, and need for tracheostomy. However, identifying which infants are at increased risk can be challenging. In this study, we sought to investigate the utility of the inotropic score (IS) and vasoactive inotropic score (VIS) as tools to predict significant clinical outcomes and overall survival in patients with CDH. Additionally, we evaluated the correlation between IS/VIS and postnatal echocardiographic variables.

METHODS

This was a retrospective chart review of 57 patients with CDH whose postnatal care was based on a standardized institutional protocol. We calculated the IS/VIS at 6-, 12-, 24-, 48 hours of life (HOL), on the day of CDH repair and 24- and 48 hours after surgical repair. The association of these scores with postnatal echocardiographic markers was analyzed using Pearson's correlation and linear regression, while logistic regression was used for binary outcomes, and Cox proportional hazards regression was used to assess associations with survival.

RESULTS

We found that every one-unit increase in IS/VIS at 6 HOL was associated with 13% increase in the odds of ECMO (p = 0.034) and 10.1% increase in risk of death (p = 0.021). An increase in IS/VIS at 12-, 24- and 48-HOL was associated with posterior septal bowing in the first postnatal echocardiogram (p < 0.05 for all). Additionally, we noted an inverse relationship between IS (r = -0.281, p = 0.036) and VIS (r = -0.288, p = 0.031) on the day of repair and left ventricle (LV) systolic function in first postnatal echocardiogram. Increase in IS (r = -0.307, p = 0.024) and VIS (r = -0.285, p = 0.037) on the day of repair was associated with decreased LV function on the post-repair echocardiogram.

CONCLUSION

This retrospective study showed a significant association between IS/VIS obtained at various time points with clinical outcomes and echocardiographic findings in CDH, which could be used to guide prognosis and management in this patient population.

Blood transfusion is associated with increased mortality for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation support

BACKGROUND AND OBJECTIVES

Blood transfusion is frequently needed to maintain adequate haemostasis and improve oxygenation for patients treated with extracorporeal membrane oxygenation (ECMO). It is more so for neonates with immature coagulation systems who require surgical intervention such as congenital diaphragmatic hernia (CDH) repair. There is growing evidence suggesting an association between blood transfusions and increased mortality. The aim of this study is to evaluate the association of blood transfusions during the peri-operative period of CDH repair, among other clinical parameters, with mortality in neonates undergoing on-ECMO CDH repair.

MATERIALS AND METHODS

We performed a single centre retrospective chart review of all neonates with CDH undergoing on-ECMO surgical repair from January 2010 to December 2020. Logistic regression was used to investigate associations with survival status.

RESULTS

Sixty-two patients met the inclusion criteria. Platelet transfusions (odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.06-1.90) in the post-operative period and ECMO duration (OR 1.17, 95% CI: 1.05-1.30) were associated with increased mortality. Major bleeding complications had the strongest association with mortality (OR 10.98, 95% CI: 3.27-36.91). Gestational age, birth weight, Apgar scores, sex, blood type, right versus left CDH, venovenous versus venoarterial ECMO and duration of ECMO before CDH repair and circuit change after adjusting for ECMO duration were not significantly associated with survival.

CONCLUSION

Platelet transfusion in the post-operative period and major bleeding are associated with increased mortality in CDH neonates with surgical repair. The data suggest a need to develop robust plans for monitoring and preventing coagulation aberrancies during neonatal ECMO support.

Mortality and Morbidity in Premature Infants: An East and West Comparative Study

OBJECTIVE

Survival of preterm infants differs dramatically depending on birthplace. No previous studies have compared outcomes of preterm infants between low middle-income and high-income countries such as India and the United States. The purpose of this study is to evaluate differences in care practices, resources, mortality, and morbidities in preterm infants with birth weight 700 to 1,500 g between two major neonatal centers in these countries.

STUDY DESIGN

This is a retrospective cohort study with de-identified data from Fernandez Hospital (FH) in Hyderabad, India, and Texas Children's Hospital (TCH) in Houston, TX, for infants born January 2016 to December 2018, and weighing 700 to 1,500 g at birth. The primary outcome was death before hospital discharge.

RESULTS

Of 1,195 infants, 736 were admitted to FH and 459 were admitted to TCH. After controlling for differences in gestational age, small for gestational age, and antenatal corticosteroid use, TCH patients had lower mortality before hospital discharge (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI]: 0.16-0.48, p < 0.001) and more bronchopulmonary dysplasia (BPD; aOR = 2.2, 95% CI: 1.51-3.21, p < 0.001). The composite outcome of death or BPD and death or any major morbidity (BPD or intraventricular hemorrhage grade II or more or periventricular leukomalacia grade II or more or retinopathy of prematurity requiring treatment) were not different.

CONCLUSION

In this study, TCH infants had decreased odds of death before hospital discharge compared with FH but higher odds of BPD, which may be related to increased survival and differences in care practices.

KEY POINTS

· Few studies compared outcomes of premature infants between different high-income countries.. · There are no studies comparing preterm infants between low middle-income and high-income countries such as India and the United States.. · This study evaluated detailed comparison of care practices and infrastructure of NICUs in India and United states..

Oxygenation Factors Associated with Retinopathy of Prematurity in Infants of Extremely Low Birth Weight

OBJECTIVE

To study characteristics of oxygenation during the first 2 postnatal months and correlation with the occurrence and severity of retinopathy of prematurity (ROP) among infants of extremely low birth weight.

STUDY DESIGN

This retrospective study analyzed the incidence and severity of hyperoxemia and hypoxemia while on respiratory support with or without supplemental oxygen among infants of extremely low birth weight (birth weight <1000 g) admitted to the neonatal intensive care unit during 2016-2020. The findings were correlated with the occurrence and severity of ROP after adjusting for baseline covariates.

RESULTS

After adjusting for differences in baseline demographic and clinical features, the group with severe ROP was exposed to greater fraction of inspired oxygen (FiO₂) (P = .001) and experienced more frequent FiO₂ titration adjustments (P = .001) compared with the group without ROP. Ambient air hyperoxemia occurred more frequently in the group without ROP (P = .003), and iatrogenic hyperoxemia occurred more frequently in the group with severe ROP (P = .046). There were no differences in the severity of ambient and iatrogenic hyperoxemia in the study population. The group with severe ROP demonstrated more hypoxemic episodes (P = .01) and longer time spent in the severe hypoxemic range (P = .005) compared with the group without ROP.

CONCLUSIONS

Severe ROP is associated with greater FiO₂ exposure, increased iatrogenic hyperoxemia, decreased ambient air hyperoxemia, and increased hypoxemia in infants of extremely low birth weight despite a greater frequency of FiO₂ titration. This study illustrates the need for automated closed loop FiO₂ delivery systems to further optimize oxygen saturation targeting in this high-risk population.

Effects of Team Size and a Decision Support Tool on Healthcare Providers' Workloads in Simulated Neonatal Resuscitation: A Randomized Trial

INTRODUCTION

Optimal resuscitation team size for workload distribution among team members is not known. In addition, decision support tools (DSTs) are available to improve team performance, but the effect on workload is not known. Because increased workload can impair performance, we aimed to determine whether team size or use of a DST alters workload in healthcare providers (HCPs) while performing neonatal resuscitation.

METHODS

We report a substudy of a randomized, 2 × 2 factorial design study using 109 Neonatal Resuscitation Program-trained HCPs. Healthcare providers were randomized to 1 of 4 permutations, including team size of 2 versus 3 and using DST versus memory alone while performing 2 simulated neonatal resuscitations. The HCPs' workload was assessed by the National Aeronautics and Space Administration Task Load Index obtained after each scenario. Mixed effects linear models compared the effect of team size and DST use on National Aeronautics and Space Administration Task Load Index scores.

RESULTS

When all team members were combined, there was an increased workload in teams of 2 HCPs compared with teams of 3 and was primarily due to an increase in workload on the team leaders. Decision support tool use increased workload for the other team members in the first of the 2 scenarios but did not increase workload in the second scenario.

CONCLUSIONS

Teams of 2 HCPs reported a higher workload compared with teams of 3 HCPs. Decision support tool use can increase workload for other team members when first introduced as a new task. This study highlights the need to consider factors that negatively affect mental workload when determining the composition of a resuscitation team.

Mortality trends in neonatal ECMO for pulmonary hypoplasia: A review of the Extracorporeal Life Support Organization database from 1981 to 2016

BACKGROUND

The purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years.

METHODS

Retrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated.

RESULTS

Thirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p < 0.001). Mortality decreased significantly over time for all groups (p < 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p < 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012).

CONCLUSIONS

Neonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support.

LEVEL OF EVIDENCE

II.

Meta-analysis comparing temperature on arrival at the referral hospital of newborns with hypoxic ischemic encephalopathy cooled with a servo-controlled device versus no device during transport

BACKGROUND

Therapeutic hypothermia reduces mortality and neurological injury for neonates with hypoxic ischemic encephalopathy (HIE). The aim of this meta-analysis is to evaluate use of servo-controlled devices during transport to the referral hospital.

METHODS

PubMed and Medline (Ovid) searches were used to identify studies comparing HIE patients' temperatures on arrival at the referral hospital for those cooled with servo-controlled devices versus no device during transport. Random effects models were used to conduct a meta-analysis comparing the two groups' proportion of patients arriving in the target temperature range as well as the mean and variability in body temperature on arrival. Studies' level of evidence and risk of bias were also assessed.

RESULTS

Eight published studies with total of 573 patients met the inclusion criteria, with a "B" grade of recommendation overall. A significantly higher proportion of infants cooled with a servo-controlled device arrived in the target temperature range (pooled relative risk = 2.47, 95% confidence interval: 1.46-4.17, p < 0.001). The arrival temperature in the device cooled group was on average 0.82°C lower (95% CI: 0.29-1.35°C, p = 0.002) with an 82% lower temperature variance.

CONCLUSIONS

Although the predominance of observational studies and presence of some risks of bias somewhat limits the strength of recommendation, the existing research consistently indicates that using a servo-controlled device during transport of neonates with HIE increases the probability of arriving at the referral hospital in the target temperature range, with a lower body temperature and less variability. Future research is needed to investigate differences in mortality and neurological impairment.

Fungal cutaneous microbiome and host determinants in preterm and term neonates

BACKGROUND

The neonatal cutaneous mycobiome has not been characterized in preterm infants. Invasive fungal infections in preterm neonates are associated with high mortality. The immaturity of the preterm skin predisposes neonates to invasive infection by skin colonizers. We report the clinical and host determinants that influence the skin mycobiome.

METHODS

Skin swabs from the antecubital fossa, forehead, and gluteal region of 15 preterm and 15 term neonates were obtained during the first 5 weeks of life. The mycobiome was sequenced using the conserved pan-fungal ITS2 region. Blood samples were used to genotype immune modulating genes. Clinical metadata was collected to determine the clinical predictors of the abundance and diversity of the skin mycobiome.

RESULTS

The neonatal mycobiome is characterized by few taxa. Alpha diversity of the mycobiome is influenced by antibiotic exposure, the forehead body site, and the neonatal intensive care unit (NICU) environment. Beta diversity varies with mode of delivery, diet, and body site. The host determinants of the cutaneous microbiome include single-nucleotide polymorphisms in TLR4, NLRP3,CARD8, and NOD2.

CONCLUSION

The neonatal cutaneous mycobiome is composed of few genera and is influenced by clinical factors and host genetics, the understanding of which will inform preventive strategies against invasive fungal infections.

Small Proportion of Low-Birth-Weight Infants With Ostomy and Intestinal Failure Due to Short-Bowel Syndrome Achieve Enteral Autonomy Prior to Reanastomosis

BACKGROUND

It is challenging to provide optimum nutrition in low-birth-weight (LBW) infants with short-bowel syndrome (SBS) and ostomy. This study aims to evaluate the clinical course of LBW infants with SBS and ostomy in response to enteral feeds, recognize characteristics associated with achievement of enteral autonomy prior to reanastomosis, and evaluate associated short-term outcomes.

METHODS

A retrospective analysis of 52 LBW neonates with intestinal failure (IF) caused by SBS and ostomy treated in a neonatal intensive care unit from 2012 to 2018 was performed. Clinical characteristics and short-term outcomes were studied in relation to the location of the ostomy and the success with enteral feeding achieved prior to reanastomosis.

RESULTS

Of the 52 infants with SBS, jejunostomy, ileostomy, and colostomy were present in 9, 40, and 3 infants, respectively. Fourteen (26.92%) infants achieved enteral autonomy transiently, and 7 (13.46%) sustained until reanastomosis. All 9 infants with jejunostomy were parenteral nutrition dependent, compared with 22 with ileostomy and none with colostomy (P = 0.002). Infants who achieved enteral autonomy showed lower incidence of cholestasis (P = 0.038) and better growth velocity (P = 0.02) prior to reanastomosis.

CONCLUSIONS

A minority of LBW infants with SBS and ostomy achieved enteral autonomy prior to reanastomosis. Distal ostomy (ileostomy and colostomy), reduced cholestasis, and better growth were associated with achievement of enteral autonomy. Our report highlights the challenges in establishing enteral autonomy in LBW infants with IF and ostomy, and the feasibility of that approach in a minority of patients, with tangible benefits.

Evaluation of a Simple Weight-Based Screening Tool for Asymptomatic Neonatal Hypoglycemia

The objective of this study was to determine if the use of weight-based criteria to screen for asymptomatic hypoglycemia is consistent with using percentile curves to determine small and large for gestational age status. A retrospective chart review of 892 term infants in the normal nursery was performed. The degree of agreement in screening recommendations between weight-based criteria and the Lubchenco, Oken, and Olsen percentile curves was determined using Cohen's κ and McNemar's test. Agreement was lower between Lubchenco and Olsen or Oken (0.470, 0.509, respectively) than with weight-based criteria (Lubchenko = 0.532; Oken = 0.566; and Olsen = 0.582). Weight-based criteria recommended screening 12% and 7% fewer patients than Lubchenko and Oken, respectively (P < .001), but was equally likely to screen infants as Olsen (P = .579). Simple weight-based criteria for asymptomatic hypoglycemia screening can identify infants at risk for hypoglycemia in a manner consistent with current guidelines.

Identifying Aspiration Among Infants in Neonatal Intensive Care Units Through Occupational Therapy Feeding Evaluations

IMPORTANCE

When a neonate's sucking, swallowing, and breathing are disorganized, oropharyngeal aspiration often occurs and results in illness, developmental problems, and even death. Occupational therapists who work in the neonatal intensive care unit (NICU) need to identify neonates who are at risk for aspirating so they can provide appropriate treatment.

OBJECTIVE

To ascertain whether client factors and performance skills of infants ages 0-6 mo during occupational therapy feeding evaluations are related to results of videofluoroscopic swallowing studies (VFSSs).

DESIGN

Retrospective chart reviews.

SETTING

187-bed NICU in a nonprofit teaching hospital.

PARTICIPANTS

A purposive sample of 334 infants ages 0-6 mo, ≥33 wk gestational age at birth, admitted to a Level II, III, or IV NICU as defined by the American Academy of Pediatrics.

OUTCOMES AND MEASURES

Neonates were administered a feeding evaluation by an occupational therapist and a VFSS by a speech-language pathologist, which yielded information about client factors and performance skills.

RESULTS

Signs and symptoms of aspiration on the evaluations were significantly associated with VFSS results. Of 310 patients, 79 had silent aspiration. Of 55 infants who demonstrated no aspiration symptoms during the feeding evaluation, 45% demonstrated aspiration symptoms on the VFSS, and 55% aspirated on the VFSS but demonstrated no symptoms of aspiration.

CONCLUSIONS AND RELEVANCE

Aspiration among infants occurs inconsistently and depends on client factors, contexts, and environments. Occupational therapists are encouraged to assess an infant's feeding over several sessions to obtain a more accurate picture of the infant's feeding status.

WHAT THIS ARTICLE ADDS

This study provides information that helps occupational therapists identify infants at risk for aspiration and make optimal recommendations regarding safe feeding practices and appropriate referrals for a VFSS. Making appropriate referrals for VFSS is also important in preventing unnecessary exposure to radiation for preterm infants.

Very preterm infants who receive transitional formulas as a complement to human milk can achieve catch-up growth

OBJECTIVE

To evaluate the growth of premature infants fed a postdischarge diet of human milk (HM) complemented with transitional formula (TF) as compared with those fed TF only.

STUDY DESIGN

In this prospective cohort study, 51 infants' diets and anthropometrics were collected at discharge and at 12-15 months corrected gestational age.

RESULTS

Post discharge, infants in both groups exhibited similar growth velocities and changes in z-scores. The duration of infants' HM consumption was not correlated with weight gain (r = -0.25, p = 0.26). The duration of complementary TF feeds also did not correlate with increased growth (r = -0.11, p = 0.44). Both groups achieved catch-up growth and displayed growth velocities that significantly exceeded the upper limit of the World Health Organization (WHO) weight growth standard (p < 0.001).

CONCLUSIONS

Preterm infants receiving HM and complementary TF post discharge had growth velocities at or exceeding weight gain projected by the WHO growth standard for term infants.

Neonatologists less frequently discuss long term complications: A simulation-based study of prenatal consults beyond the threshold of viability

BACKGROUND

Guidelines exist for counseling expectant families of infants at periviable gestational ages (22-25 weeks), but it is much more common for neonatologists to counsel families at gestational ages beyond the threshold of viability when several aspects of these guidelines do not apply. We aimed to develop an understanding of what information is shared with mothers at risk of preterm delivery beyond periviability and to evaluate communication skills of our participants.

METHODS

We developed a checklist of elements to include in counseling based on a comprehensive literature review. The checklist was divided into an information sharing section and a connect score. The information sharing list was sub-divided into general information and specific complications. Neonatologists engaged in a simulated prenatal counseling session with a standardized patient. Videotaped encounters were then analyzed for checklist elements.

RESULTS

Neonatologists all scored well in communication using our tool and two other validated communication tools - the SEGUE and the analytic global OSCE. There was no difference in scoring based on years of experience or level of training. Information sharing from neonatologists more often discussed general information over specific. Neonatologists also focused more on early outcomes over long-term outcomes. Only 12% of neonatologists quoted the correct survival rate for the case.

CONCLUSIONS

Neonatologists generally communicate well but share less information specific to prematurity and the long-term sequelae of prematurity. Our tool may be used to test if other interventions improve information sharing or communication.

Early proton magnetic resonance spectroscopy during and after therapeutic hypothermia in perinatal hypoxic-ischemic encephalopathy

BACKGROUND

Hypoxic-ischemic encephalopathy (HIE) remains a significant cause of mortality and neurodevelopmental impairment despite treatment with therapeutic hypothermia. Magnetic resonance H¹-spectroscopy measures concentrations of cerebral metabolites to detect derangements in aerobic metabolism.

OBJECTIVE

We assessed MR spectroscopy in neonates with HIE within 18-24 h of initiating therapeutic hypothermia and at 5-6 days post therapeutic hypothermia.

MATERIALS AND METHODS

Eleven neonates with HIE underwent MR spectroscopy of the basal ganglia and white matter. We compared metabolite concentrations during therapeutic hypothermia and post-therapeutic hypothermia and between moderate and severe HIE.

RESULTS

During therapeutic hypothermia, neonates with severe HIE had decreased basal ganglia N-acetylaspartate (NAA; 0.62±0.08 vs. 0.72±0.05; P=0.02), NAA + N-acetylaspartylglutamate (NAAG; 0.66±0.11 vs. 0.77±0.06; P=0.05), glycerophosphorylcholine + phosphatidylcholine (GPC+PCh; 0.28±0.05 vs. 0.38±0.06; P=0.02) and decreased white matter GPC+PCh (0.35±0.13 vs. 0.48±0.04; P=0.02) compared to neonates with moderate HIE. For all subjects, basal ganglia NAA decreased (-0.08±0.07; P=0.01), whereas white matter GPC+PCh increased (0.03±0.04; P=0.04) from therapeutic hypothermia MRI to post-therapeutic-hypothermia MRI. All metabolite values are expressed in mmol/L.

CONCLUSION

Decreased NAA and GPC+PCh were associated with greater HIE severity and could distinguish neonates who might benefit most from targeted additional neuroprotective therapies.

Premature small for gestational age infants fed an exclusive human milk-based diet achieve catch-up growth without metabolic consequences at 2 years of age

OBJECTIVE

To compare postdischarge growth, adiposity and metabolic outcomes of appropriate for gestational age (AGA) versus small for gestational age (SGA) premature infants fed an exclusive human milk (HM)-based diet in the neonatal intensive care unit.

DESIGN

Premature infants (birth weight ≤1250 g) fed an exclusive HM-based diet were examined at 12-15 months corrected gestational age (CGA) (visit 1) for anthropometrics, serum glucose and non-fasting insulin, and at 18-22 months CGA (visit 2) for body composition by dual-energy X-ray absorptiometry.

RESULTS

Of 51 children, 33 were AGA and 18 were SGA at birth. The SGA group had weight gain (g/day) equal to AGA group during the follow-up period. SGA had a significantly greater body mass index (BMI) z-score gain from visit 1 to visit 2 (0.25±1.10 vs -0.21±0.84, p=0.02) reflecting catch-up growth. There were no significant differences in total fat mass (FM) and trunk FM between groups. SGA had significantly lower insulin level (5.0±3.7 vs 17.3±15.1 µU/mL, p=0.02) and homeostatic model of assessment-insulin resistance (1.1±0.9 vs 4.3±4.1, p=0.02). Although regional trunk FM correlated with insulin levels in SGA (r=0.893, p=0.04), they had lower insulin level compared with AGA and no difference in adiposity.

CONCLUSIONS

SGA premature infants who received an exclusive HM-based diet exhibited greater catch-up growth without increased adiposity or elevated insulin resistance compared with AGA at 2 years of age. An exclusive HM-based diet may improve long-term body composition and metabolic outcomes of premature infants with ≤1250 g birth weight, specifically SGA.

Efficacy of different cerclage suture materials in reducing preterm birth

Objective: To compare the efficacy of monofilament suture, braided polyester thread, and 5 mm tape suture in reducing preterm birth (PTB).Study design: Women who received a cerclage at Touro Infirmary, New Orleans, LA, USA, between 1 January, 2011 and 31 December, 2016 were identified using ICD-9/10 codes. All charts were reviewed for demographic and obstetrical variables including gestational age (GA) at delivery.Results: Of 145 women who received a cerclage, 36 were excluded due to incomplete charts leaving 109 for analysis. There was no significant difference in gestational age at cerclage placement or delivery among women with monofilament, braided, or 5 mm tape cerclages (p = .936 and p = .919, respectively) nor was there a difference in the proportion who delivered at ≥32, 34, or 37 weeks across groups with differing cerclage material (p = .270, p = .275, and p = .419, respectively). There was no difference in GA at delivery for patients who received 17-OHP compared to those who did not (p = .362). There were also no differences with respect to birth outcomes such as birthweight (p = .938), Apgar scores (p = .477, p = .430) or neonatal intensive care admission rates (NICU) (p = .304). Analysis revealed no difference in characteristics between groups including history of PTB or indication for removal (p = .371, p = .317).Conclusion: We found no difference in pregnancy prolongation when comparing different suture material used for indicated cerclages. We also found no differences with respect to rates of maternal infection or adverse neonatal outcomes among groups.RationaleThis study was conducted to evaluate the efficacy of different suture materials in increasing gestational age at delivery and reducing preterm birth.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit

BACKGROUND

Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics.

OBJECTIVES

The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI.

METHODS

A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted.

RESULTS

One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study.

CONCLUSIONS

The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Lung omics signatures in a bronchopulmonary dysplasia and pulmonary hypertension-like murine model

Bronchopulmonary dysplasia (BPD), the most common chronic lung disease in infants, is associated with long-term morbidities, including pulmonary hypertension (PH). Importantly, hyperoxia causes BPD and PH; however, the underlying mechanisms remain unclear. Herein, we performed high-throughput transcriptomic and proteomic studies using a clinically relevant murine model of BPD with PH. Neonatal wild-type C57BL6J mice were exposed to 21% oxygen (normoxia) or 70% oxygen (hyperoxia) during postnatal days (PNDs) 1-7. Lung tissues were collected for proteomic and genomic analyses on PND 7, and selected genes and proteins were validated by real-time quantitative PCR and immunoblotting analysis, respectively. Hyperoxia exposure dysregulated the expression of 344 genes and 21 proteins. Interestingly, hyperoxia downregulated genes involved in neuronal development and maturation in lung tissues. Gene set enrichment and gene ontology analyses identified apoptosis, oxidoreductase activity, plasma membrane integrity, organ development, angiogenesis, cell proliferation, and mitophagy as the predominant processes affected by hyperoxia. Furthermore, selected deregulated proteins strongly correlated with the expression of specific genes. Collectively, our results identified several potential therapeutic targets for hyperoxia-mediated BPD and PH in infants.

Prophylactic Dextrose Gel Does Not Prevent Neonatal Hypoglycemia: A Quasi-Experimental Pilot Study

OBJECTIVE

To test the hypothesis that prophylactic dextrose gel administered to newborn infants at risk for hypoglycemia will increase the initial blood glucose concentration after the first feeding and decrease neonatal intensive care unit (NICU) admissions for treatment of asymptomatic neonatal hypoglycemia compared with feedings alone.

STUDY DESIGN

This quasi-experimental study allocated asymptomatic at-risk newborn infants (late preterm, birth weight <2500 or >4000 g, and infants of mothers with diabetes) to receive prophylactic dextrose gel (Insta-Glucose; Valeant Pharmaceuticals North America LLC, Bridgewater, New Jersey); other at-risk infants formed the control group. After the initial feeding, the prophylactic group received dextrose gel (0.5 mL/kg) rubbed into the buccal mucosa. The blood glucose concentration was checked 30 minutes later. Initial glucose concentrations and rate of NICU admissions were compared between the prophylactic group and controls using bivariate analyses. A multivariable linear regression compared first glucose concentrations between groups, adjusting for at-risk categories and age at first glucose concentration.

RESULTS

There were 236 subjects (72 prophylactic, 164 controls). The first glucose concentration was not different between the prophylactic and control groups in bivariate analysis (52.1 ± 17.1 vs 50.5 ± 15.3 mg/dL, P = .69) and after adjusting for covariates (P  = .18). Rates of NICU admission for treatment of transient neonatal hypoglycemia were 9.7% and 14.6%, respectively (P = .40).

CONCLUSIONS

Prophylactic dextrose gel did not reduce transient neonatal hypoglycemia or NICU admissions for hypoglycemia. The carbohydrate concentration of Insta-Glucose (77%) may have caused a hyperinsulinemic response, or alternatively, exogenous enteral dextrose influences glucose homeostasis minimally during the first few hours when counter-regulatory mechanisms are especially active.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02523222.

The strong correlation between neonatal early-onset Group B Streptococcal disease and necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a leading cause of newborn gastrointestinal emergencies, affecting 1-3 per 1000 live births. Although NEC has been linked to a microbial etiology, associations with maternal intrapartum and resultant newborn early-onset invasive Group B streptococcus (EO-GBS) have been weakly defined.

OBJECTIVE

The study aim was to determine the relationship between EO-GBS and NEC.

STUDY DESIGN

Data from 2008 to 2015 were collected from pediatric records with ICD diagnosis codes consistent with all stages of NEC, with the exception of neonatal EO-GBS data (only available 2011-2015).

RESULTS

For the 131 newborns meeting inclusion criteria, the mean gestational age (GA) and birthweight at delivery was 30.2 weeks and 1449 g. Maternal comorbidities were not associated with a more advanced stage of NEC, however male gender (OR 3.2, p < .001), lower mean 1 (OR = 0.89, p = .045) and 5 min Apgar scores (OR = 0.84, p = .009) were significantly associated with higher NEC stage, after controlling for GA. Infectious morbidities including chorioamnionitis (OR = 1.5, p = .553) and intrapartum antibiotic administration (OR = 1.3, p = .524) were not significantly associated with higher NEC stage. Neither neonatal sepsis workup (OR = 0.27, p = .060) nor positive blood culture (OR = 0.97, p = .942) prior to NEC diagnosis were statistically significant. Type of feed prior to diagnosis (p = .530) was not significantly associated with NEC stage, however, expressed breast milk tended to be protective against higher stage of NEC (OR = 0.49, p = .055). Type of feed included total parenteral nutrition, mother's or donor expressed breast milk, trophic, full and high calorie feeds. Of the 579 newborns admitted from 2011 to 2015, 13 (2%) were diagnosed with EO-GBS and 64 met diagnostic criteria for NEC. GBS positive newborns had significantly higher odds of NEC (OR = 5.37, p = .009). NEC stage was not significantly different for patients with GBS positive vs. GBS negative mothers (p = .732), nor was there a significant difference in GA (p = .161).

CONCLUSION

Our study is the first to describe a strong correlation between neonatal EO- GBS disease and NEC, with more than a five-fold increase in the odds of developing NEC in newborns of GBS positive mothers.

PURPOSE

To investigate a possible relationship between EO-GBS disease and the neonatal diagnosis of NEC. Secondary analysis will determine if maternal antepartum and intrapartum factors along with neonatal variables contribute to a more advanced stage of NEC by retrospective chart review of patient data collected at Children's Hospital: New Orleans.

Bleeding Complications and Mortality in Neonates Receiving Therapeutic Hypothermia and Extracorporeal Membrane Oxygenation

OBJECTIVE

 The objective of this study was to compare complications and mortality in neonates with hypoxic ischemic encephalopathy (HIE) on extracorporeal membrane oxygenation (ECMO) who did and did not receive therapeutic hypothermia (TH).

STUDY DESIGN

 The Extracorporeal Life Support Organization registry was queried from 2005 to 2013 to identified infants with HIE. Infants ≤30 days of age with HIE on respiratory ECMO were included. Fisher's exact test and the Wilcoxon's rank-sum test were used to compare neonates with and without TH. Logistic regression was used to examine the association of TH with complications and mortality.

RESULTS

 There were no difference between neonates with HIE who did (n = 78) and did not (n = 109) receive TH in demographics, severity of illness, complications, and mortality (p = 0.21).

CONCLUSION

 No differences in complications or mortality in neonates with HIE and respiratory ECMO were observed between those who did and did not receive TH. We suggest that for neonates requiring respiratory ECMO who also have HIE, TH is not contraindicated.

Improving communication between obstetric and neonatology teams for high-risk deliveries: a quality improvement project

Summoning is a key component of communication between obstetrics and neonatal resuscitation team (NRT) in advance of deliveries. A paging system is a commonly used summoning tool. The timeliness and information contained in the page help NRT to optimally prepare for postdelivery infant care. Our aim was to increase the frequency that summoning pages contained gestational age and reason for NRT attendance to >90%. At baseline, 8% of pages contained gestational age and 33% of pages contained a reason for NRT attendance. Sequential Plan-Do-Study-Act cycles were used as our model for quality improvement. During the 8-month improvement period, the per cent of pages increased to 97% for gestational age and 97% for reason for NRT attendance. Measures of page timeliness, our balancing measure, did not change. Summoning communication between obstetric and NRT is crucial for optimal perinatal outcomes. The active involvement of all stakeholders throughout the project resulted in the development of a standardised paging tool and a more informative paging process, which is a key communication tool used in many centres.

Use of Vasopressin in Neonatal Intensive Care Unit Patients With Hypotension

OBJECTIVE

To evaluate the safety and efficacy of vasopressin for the treatment of hypotension in patients admitted to neonatal intensive care units (NICUs).

METHODS

Vasopressin use in 69 infants admitted to our NICU between 2011 and 2014 was examined. Data evaluated included demographics; serum creatinine, sodium, and lactate concentrations; urine output; and systolic, diastolic, and mean blood pressures (BPs). Parameters prior to vasopressin use were compared to those at maximum dose.

RESULTS

Vasopressin use was associated with increased urine output (p < 0.05), and increased systolic (p < 0.0005), diastolic (p < 0.01), and mean (p < 0.001) BP. There were no differences in sodium or lactate concentrations before vs during infusion; vasopressin use was not associated with hyponatremia (sodium < 130 mEq/L) at the maximum dose.

CONCLUSIONS

Vasopressin for the treatment of neonatal hypotension appears safe and was efficacious in raising BP. These data suggest that vasopressin could be considered a viable option in the treatment regimen in hypotensive infants in the NICU.

Comparison of traditional orthodontic polishing systems with novel non-orthodontic methods for residual adhesive removal

BACKGROUND

Following the debonding of orthodontic brackets, the removal of residual adhesive from the enamel surface is required. Published adhesive removal protocols present conflicting advice.

AIMS

The present study evaluated the surface roughness of enamel after debonding and instrumentation with non-traditional orthodontic polishing systems.

METHODS

The facial aspects of 35 extracted human incisor teeth were scanned with a surface profilometer for surface roughness prior to the bonding of orthodontic brackets. After debonding, residual adhesive was removed with a 12-fluted titanium carbide bur. The teeth were randomly divided into seven groups (N = 5 per group) and the enamel surface was polished with one of seven products. All samples were re-scanned for surface roughness and subjectively evaluated via SEM.

RESULTS

There was no significant difference in enamel surface roughness between the groups when compared using surface profilometry. Visual observations from the SEM evaluations demonstrated differences in the enamel surface at the microscopic level that were not detected by profilometric analysis.

CONCLUSIONS

The present study found no statistically significant difference in mean enamel smoothness change from pretreatment to post-treatment between the seven polishing methods studied via profilometer surface reading measurements. An SEM analysis showed visual differences in enamel striations viewed at 1000x magnification in a comparison of traditional versus non- traditional polishing methods.

Prevalence and Severity of Anemia in Children Hospitalized with Acute Heart Failure

OBJECTIVE

Anemia is common among adult heart failure patients and is associated with adverse outcomes, but data are lacking in children with heart failure. The purpose of this study was to determine the prevalence of anemia in children hospitalized with acute heart failure and to evaluate the association between anemia and adverse outcomes.

DESIGN

Review of the medical records of 172 hospitalizations for acute heart failure.

SETTING

Single, tertiary children's hospital.

PATIENTS

All acute heart failure admissions to our institution from 2007 to 2012.

INTERVENTIONS

None.

OUTCOME MEASURES

Composite endpoint of death, mechanical circulatory support deployment, or cardiac transplantation.

RESULTS

Patients ages ranged in age from 4 months to 23 years, with a median of 7.5 years, IQR 1.2, 15.9. Etiologies of heart failure included: dilated cardiomyopathy (n = 125), restrictive cardiomyopathy (n = 16), transplant coronary artery disease (n = 18), ischemic cardiomyopathy (n = 7), and heart failure after history of congenital heart disease (n = 6). Mean hemoglobin concentration at admission was 11.8 g/dL (±2.0 mg/dL). Mean lowest hemoglobin prior to outcome was 10.8 g/dL (±2.2 g/dL). Anemia (hemoglobin <10 g/dL) was present in 18% of hospitalizations at admission and in 38% before outcome. Anemia was associated with increased risk of death, transplant, or mechanical circulatory support deployment (adjusted odds ratio 1.79, 95% confidence interval = 1.12-2.88, P = .011). For every 1 g/dL increase in the patients' lowest hemoglobin during admission, the odds of death, transplant, or mechanical circulatory support deployment decreased by 18% (adjusted odds ratio = 0.82, 95% confidence interval = 0.74-0.93, P = 0.002).

CONCLUSIONS

Anemia occurs commonly in children hospitalized for acute heart failure and is associated with increased risk of transplant, mechanical circulatory support, and inhospital mortality.

Enamel surface roughness of preferred debonding and polishing protocols

OBJECTIVE

This study investigated the surface roughness of enamel after debonding and instrumentation with commonly used methods.

METHODS

Part I: a survey was sent to active members of the American Association of Orthodontists to determine popular bonding, debonding, and polishing protocols. Part II: brackets were bonded to the buccal surface of 30 extracted human premolar teeth. After debonding, residual adhesive was removed with 12-, 16-, and 20-fluted titanium carbide burs as based upon the survey results. The teeth were scanned with a surface profilometer for surface roughness. Part III: the teeth were further polished using a Reliance Renew polishing point or a prophy cup with pumice and rescanned for surface roughness.

RESULTS

Part I: the majority of respondents used a generic bracket-removing plier to remove fixed appliances (53%) and a high-speed handpiece for adhesive removal (85%). The most popular bur was a 12-fluted carbide bur without water spray. The majority of respondents used pumice paste and/or Reliance Renew points after adhesive removal. Part II: there was a significant difference in enamel surface roughness when 12-, 16-, and 20-fluted carbide burs were compared via surface profilometry. Part III: further polishing with a Reliance Renew point or a prophy cup and pumice did not provide a significantly smoother surface.

CONCLUSIONS

The results show large variation in debonding and polishing techniques. Creating a smooth enamel surface is equally possible with 12- or 20-fluted carbide burs. Further polishing with pumice and prophy cup or Renew point does not provide an enamel smoother surface.

Relationship between hand-skill exercises and other admissions criteria and students' performance in dental school

The aim of this study was to investigate the existence of correlations between dental admissions criteria, including a chalk carving exercise, and students' subsequent academic performance. The retrospective cohort study examined the records of dental students at Louisiana State University Health Science Center School of Dentistry for the years 1998 to 2008. Only those students who could be categorized into the following four groups were included: 1) those who graduated in the top 10% of their class, 2) those who graduated in the bottom 10% of their class, 3) those who repeated a year of dental school, and 4) those who were dismissed or resigned. The study sample consisted of 176 students: 62 in the first group, 62 in the second group, 25 in the third group, and 27 in the fourth group. Data collected were each student's undergraduate grade point average (GPA); chalk carving score; undergraduate biology, chemistry, physics (BCP) GPA; Dental Admission Test (DAT) Academic Average; Perceptual Ability Test (PAT) score of the DAT; total DAT score; grade in preclinical operative dentistry class; grade in morphology and occlusion class; and dental school GPA at graduation. The results showed that only the undergraduate GPA and BCP GPA were significantly higher for students in the top 10% of their class than for other groups. The only positive correlation involving the chalk carving scores was with the preclinical operative dentistry course grade. This study thus found limited correlations between this institution's admissions criteria and its students' success in dental school.

Perceptions of uncivil student behavior in dental education

Students and faculty members in the health professions classroom are expected to exhibit professional behaviors that are conducive to maintaining a positive learning environment, but there is little published research concerning incivility in the area of dental education. The aim of this study was to evaluate differences in perceptions of incivility between dental faculty and students, between students in different courses of study, and between students in different years of dental study. The study utilized an anonymous electronic survey of all dental faculty and administrators and all dental, dental hygiene, and dental laboratory technology students at a single institution. The survey instrument contained questions concerning perceived uncivil behavior in the classroom and clinical settings. Response rates were 54% for faculty and administrators and ranged from 60% to 97% for students in various years and programs. The results were analyzed based on gender, course of study, year of study, and ethnicity. Significant differences were found regarding perceptions of civil behaviour between faculty and students, male and female students, the year of study, and the course of study. These differences point to the need for further research as well as administrative leadership and faculty development to define guidelines in this area in order to ensure a positive learning environment.