Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors.

Aim: Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth. Methods: A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression. Results: Between 11/7/22-12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns. Conclusion: Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.

Laryngeal Mask Use in the Neonatal Population: A Survey of Practice Providers at a Regional Tertiary Care Center in the United States.

OBJECTIVE: The aim of this study was to evaluate the level of training, awareness, experience, and confidence of neonatal practice providers in the use of laryngeal mask (LM), and to identify the barriers in its implementation in the neonatal population. STUDY DESIGN: Descriptive observational study utilizing an anonymous online questionnaire among healthcare providers at the Oklahoma Children's Hospital who routinely respond to newborn deliveries and have been trained in the Neonatal Resuscitation Program (NRP). Participants included physicians, trainees, nurse practitioners, nurses, and respiratory therapists. RESULTS: Ninety-five participants completed the survey (27.5% response rate). The sample consisted of 77 NRP providers (81%), 11 instructors (12%), and 7 instructor mentors (7%). Among 72 respondents who had undergone LM training, 51 (54%) had hands-on manikin practice, 4 (4%) watched the American Academy of Pediatrics (AAP) NRP educational video, and 17 (18%) did both. Nurses (39 out of 46) were more likely to have completed LM training than were physicians (31 out of 47). With only 11 (12%) participants having ever placed a LM in a newly born infant, the median confidence for LM placement during neonatal resuscitation was 37 on a 0 to 100 scale. Frequently reported barriers for LM use in neonates were limited experience (81%), insufficient training (59%), preference for endotracheal tube (57%), and lack of awareness (56%). CONCLUSION: While the majority of the neonatal practice providers were trained in LM placement, only a few had ever placed one in a live newborn, with a low degree of confidence overall. Future practice improvement should incorporate ongoing interdisciplinary LM education, availability of LM in the labor and delivery units, and promotion of awareness of LM as an alternative airway. KEY POINTS: · LM is underutilized as an alternative airway.. · Insufficient experience and training limit LM use.. · Providers confidence with LM placement is low..

Multicenter study assessing physicians' and transport teams' attitudes and expectations about utilizing telemedicine to manage critical neonatal transports.

BACKGROUND: Managing critically ill neonates has unique challenges, and the transport team plays an important role in stabilizing and facilitating the transfer of these neonates from lower-level nurseries to tertiary centers, and the use of telemedicine in transport (tele-transport) can potentially benefit patient care. We conducted a multicenter study to assess the readiness for utilizing telemedicine as an adjunct to guide the care of critically ill neonates among physicians and transport team members (TTMs). This is the first multicenter study that explored physicians' and TTMs' perceptions of telemedicine usage and its value in neonatal transport. METHODS: A confidential, voluntary survey on pre-implementation attitudes toward telemedicine usage during neonatal transport was conducted as part of a quality improvement initiative. This survey involved physicians and TTMs from four academic institutions whose responses were entered into an online survey using REDCap®. The survey inquired about satisfaction with the current practice of phone consultation and the perception of using telemedicine to optimize the management of neonates during transport. RESULTS : The overall response rate for the survey was 60.1%; 82 of 127 (64.6%) physicians and 64 of 116 (55.2%) TTMs responded to the surveys. Half of the physicians and less than one-fourth of the TTMs had prior experience with telemedicine other than that used on neonatal transport. TTMs expressed greater concern about the inconvenience of video (55% vs. physicians 35% agree or strongly agree) and its time consumption (84% vs. physicians 50%). More than 70% of physicians and less than half of TTMs endorsed the potential for added value and quality improvement with video capability. Almost half of TTMs reported concern about video calls reducing their autonomy in patient care. Physicians expressed confidence in management decisions they would make after video calls (72% confident or very confident) and less confidence (49%) about both the phone assessment by TTMs and their decisions based on phone assessment. In contrast, TTMs were confident or very confident (94%) in both sharing their assessment over the phone and executing patient management after a phone call, compared with 70% for decisions made after video calls. CONCLUSIONS : Physicians and TTMs had distinct opinions on the use of telemedicine during neonatal transport. Physicians were more likely than TTMs to agree with statements about the potential for improving quality of care, while TTMs were more likely than physicians to say video calls would be time-consuming and inconvenient. We speculate some differences may stem from the TTMs' concern about losing their autonomy. Therefore, during implementation, it is critical for physicians and TTMs to agree on a shared mental model of indications for telemedicine during transport and its value to the patient care.

Evaluating Patients' and Neonatologists' Satisfaction With the Use of Telemedicine for Neonatology Prenatal Consultations During the COVID-19 Pandemic.

Background: During the COVID-19 pandemic, telemedicine plays a critical role in providing safe, effective healthcare services, while reinforcing social distancing and optimizing the use of personal protective equipment. In this context, the Oklahoma Children's Hospital implemented virtual neonatology prenatal visits for pregnant women with a diagnosis of fetal anomalies. While tele-consultations have been broadly used with a high degree of acceptance in rural and remote areas, satisfaction has not been assessed in this particular scenario, where patients and physicians discussing sensitive healthcare information had to rapidly adjust to this new modality. Objectives: To evaluate patients' and neonatologists' satisfaction with virtual prenatal consultations in the context of the COVID-19 pandemic and to compare satisfaction levels of patients receiving virtual consultation with those receiving in-person consults. Methods: This cross-sectional study evaluated patients' and neonatologists' satisfaction with virtual consultations. Participants included pregnant women with diagnosis of fetal anomalies who received neonatology prenatal consultations at Oklahoma Children's Hospital, either in-person or through telemedicine, from May to mid-November 2020, and neonatologists providing virtual prenatal consultations in the same period. Virtual visits were delivered via Zoom Pro™. Patients and physicians who agreed to participate rated acceptability completing an anonymous 5-point Likert scale survey. Item frequencies and means for categories of items were computed by group (video-consult patients, in-person patients, physicians) and analyzed, using Welch's t for unequal sample size. Results: Overall consultation quality was rated good or excellent by 35 (100%) video-consult patients and 12 (100%) in-person patients. Patient group means computed on six 5-point Likert items about patient-physician communication did not differ significantly, video-consult: M = 28.71 (2.22); in-person consult: M = 28.92 (1.78) (p = 0.753263). All eight physicians (100%) agreed or strongly agreed that telemedicine was effective, using a 5-point Likert scale, and their combined consultation quality score computed on 10 survey questions was high: M = 46.4 (3.11). Conclusion: Despite patient inexperience with tele-consultations, the quick implementation of telemedicine, and the sensitive reason for the visit, patients and physicians were highly satisfied with virtual visits. Telemedicine is a safe, effective alternative for providing neonatology prenatal consultations for pregnant women with diagnosis of fetal anomalies during the pandemic.

Barriers and strategies to integrate medical genetics and primary care in underserved populations: a scoping review.

Despite clinical and technological advances, serious gaps remain in delivering genetic services due to disparities in workforce distribution and lack of coverage for genetic testing and counseling. Genetic services delivery, particularly in medically underserved populations, may rely heavily on primary care providers (PCPs). This study aims to identify barriers to integrating genetic services and primary care, and strategies to support integration, by conducting a scoping review. Literature synthesis found barriers most frequently cited by PCPs including insufficient knowledge about genetics and risk assessment, lack of access to geneticists, and insufficient time to address these challenges. Telegenetics, patient-centered care, and learning communities are strategies to overcome these barriers. Telegenetics supplements face-to-face clinics by providing remote access to genetic services. It may also be used for physician consultations and education. Patient-centered care allows providers, families, and patients to coordinate services and resources. Access to expert information provides a critical resource for PCPs. Learning communities may represent a mechanism that facilitates information exchange and knowledge sharing among different providers. As PCPs often play a crucial role caring for patients with genetic disorders in underserved areas, barriers to primary care-medical genetics integration must be addressed to improve access. Strategies, such as telegenetics, promotion of evidence-based guidelines, point-of-care risk assessment tools, tailored education in genetics-related topics, and other system-level strategies, will facilitate better genetics and primary care integration, which in turn, may improve genetic service delivery to patients residing in underserved communities.

Evaluation of Neonatal Services Provided in a Level II NICU Utilizing Hybrid Telemedicine: A Prospective Study.

Objective: To evaluate the safety and efficacy of premature infant treatment managed by hybrid telemedicine versus conventional care. Methods: Prospective, noninferiority study comparing outcomes of premature infants at Comanche County Memorial Hospital's (CCMH) Level II neonatal intensive care unit (NICU) with outcomes at OU Medical Center's (OUMC) Level IV NICU. All 32-35 weeks gestational age (GA) infants admitted between May 2015 and October 2017 were included. Infants requiring mechanical ventilation >24 h or advanced subspecialty care were excluded. Outcome variables were: length of stay (LOS), respiratory support, and time to full per oral (PO) feeds. Parents at both centers were surveyed about their satisfaction with the care provided. Between-group comparisons were performed by using Chi-square or Fisher's exact test. LOS was assessed for normality by using the Shapiro-Wilk test, and robust regression was used to construct a multivariable regression model to test the independent effect of location on LOS. All analyses were performed by using SAS v. 9.3 (SAS Institute, Cary, NC). Results: Data from 85 CCMH and 70 OUMC neonates were analyzed. CCMH neonates had significantly shorter LOS, reached full PO feeds sooner, and had fewer noninvasive ventilation support days. Location had a significant independent effect (p = 0.001) on LOS while controlling for GA, gender, race, surfactant use, inborn/outborn status, and 5-min APGAR scores. CCMH patients had reduced LOS of 3.01 days (95% confidence interval 1.1-4.8) than OUMC patients. Eighty-five surveys at CCMH and 66 at OUMC were analyzed. Compared with CCMH, OUMC parents reported more travel distance difficulties. 92.5% reported telemedicine experience as good or excellent, whereas 1.5% reported it as poor. Conclusion(s): Hybrid telemedicine is a safe and effective way to extend intensive neonatal care to medically underserved areas. Parental satisfaction with use of hybrid telemedicine is high and comparable to conventional care.

A Hybrid Form of Telemedicine: A Unique Way to Extend Intensive Care Service to Neonates in Medically Underserved Areas.

BACKGROUND: More than 90% of neonatal intensive care units (NICUs) in the United States are in urban areas, denying rural residents' easy NICU access. Telemedicine use for patient contact and management, although studied in adults and children, is understudied in neonates. A hybrid telemedicine system, with 24/7 neonatal nurse practitioner coverage and with a neonatologist physically present 3 days per week and telemedicine coverage the remaining days, was recently implemented at Comanche County Memorial Hospital's (CCMH) Level II NICU. OBJECTIVE: To compare outcomes of moderately ill infants between 32-35 weeks gestational age (GA) managed by our hybrid telemedicine program with outcomes of similar neonates receiving standard care in a Level IV NICU at Oklahoma University Medical Center (OUMC). DESIGN/METHODS: This was a retrospective, noninferiority study comparing outcomes of neonates receiving hybrid telemedicine versus standard care. All 32-35 weeks GA infants admitted between July 2013 and June 2015 were included. OUMC infants came from areas geographically comparable with CCMH. Infants requiring prolonged mechanical ventilation or advanced subspecialty services were excluded. Outcome variables were length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings. RESULTS: Eighty-seven neonates at CCMH and 56 neonates at OUMC were included in the analysis. Compared with neonates at OUMC, neonates at CCMH had shorter hospitalizations, fewer days of supplemental oxygen, and fewer noninvasive ventilation support days, and reached full enteral feeds sooner. CONCLUSIONS: The hybrid telemedicine system is a safe and effective strategy for extending intensive care to neonates in medically underserved areas.

Impact of Specialized Nursery Care for Late Preterm Infants on NICU Admission Rate and Length of Stay.

OBJECTIVE: To compare neonatal intensive care unit (NICU) admission rates and length of stay (LOS) of late preterm infants (LPIs) born before and after opening a specialized care nursery (SCN) at our academic, pediatric tertiary care center with ∼4,500 total deliveries annually. STUDY DESIGN: Retrospective chart review of inborn LPIs (35(0/7)-36(6/7) weeks) who were asymptomatic or minimally symptomatic at birth and delivered 7 months before the opening of the SCN (pre-SCN) or 7 months subsequently (post-SCN). Infants were excluded for major congenital anomalies or other conditions requiring immediate NICU admission. The pre-SCN options for care were standard couplet care or NICU. The post-SCN options for care were standard couplet care, SCN, or NICU. RESULTS: Pre-SCN (n = 109), 73 (67%) infants received standard couplet care, while 36 (33%) infants were ever admitted/transferred to the NICU. Post-SCN (n = 112), 59 (53%) infants received standard couplet care, while 20 (18%) were ever admitted/transferred to the NICU. A total of 33 (29%) infants were admitted/transferred to the SCN and avoided a NICU stay. Median LOS for all infants was 3 days. CONCLUSION: The frequency of LPIs admitted/transferred to the NICU decreased by ∼50% after the opening of the SCN. LOS did not differ by birth cohort, but did differ significantly by location of care (standard couplet care < SCN < NICU).

Efficacy and safety of short-term use of COX-2 inhibitors in patients after an acute stroke with musculoskeletal pain.

OBJECTIVE: Musculoskeletal pain commonly occurs in the elderly, many of whom are also prone to suffer from strokes. We studied whether short-term use (≤ 4 weeks) of cyclooxygenase-2 (COX-2) inhibitors for musculoskeletal pain in stroke patients helped them to participate in their therapies and was safe and efficacious. MATERIALS AND METHODS: Three hundred and three patients admitted consecutively with first ischemic stroke were studied. Two cohorts were defined, based on whether patients with acute stroke had sufficient musculoskeletal pain that warranted oral COX-2 inhibitors (COX-2 group) or not (case-matched controls). Primary efficacy measures were change in Fugl-Meyer (F-M) pain score and change in total functional independence measure (TFIM) scores on discharge from hospital. Safety was judged by the incidence of vascular episodes during the study period. RESULTS: From the original 303 patients, 64 patients in the COX-2 group were matched with 64 patients in the non-COX-2 group. The groups were matched for age (±5 years), gender, and admission TFIM score (± 5 points). Baseline characteristics between the 2 groups were similar. The primary and secondary outcome measures were similar between the 2 groups, except for ambulation endurance, which favored the non-COX-2 group (P < 0.03). Greater change in the pain score (less pain) was found in the COX-2 group; this effect was strongest in patients who were independent prior to their stroke (on post hoc analysis). There were too few adverse events in either group of any significance. CONCLUSIONS: The short-term use of COX-2 inhibitors reduced musculoskeletal pain in acute stroke patients, improved functional motor outcome, and were found to be safe.

Latino/as in substance abuse treatment: substance use patterns, family history of addiction, and depression.

This study describes a sample of Latino/as in substance abuse treatment. We were interested in substance use patterns, gender differences, family history of addiction, and depression. Questionnaires completed by Latino/as (N = 209) were identified from 12,000 sets completed by participants in treatment from 1993-2003. Significant gender differences emerged, with Latinas reporting higher rates of stimulant abuse and depression. A family history of substance use disorders in primary or secondary family members was reported by 91% of participants. These data suggest that understanding gender differences related to substance use and depression among Latino/as in treatment warrants attention.

Does race influence functional outcomes in patients with acute stroke undergoing inpatient rehabilitation?

OBJECTIVE: Race has been shown to affect stroke-related morbidity and mortality. The purpose of this study was to determine the influence of race on rehabilitation functional outcomes in patients with an acute stroke admitted to a designated stroke rehabilitation unit. DESIGN: A 2-yr prospective study was conducted of 670 patients admitted to an acute stroke rehabilitation unit within 30 days after an acute stroke. Demographic data along with admission and discharge Functional Independence Measure scores were recorded in a computerized stroke database. Patients participated in a standardized rehabilitation program 5 days a week for a length of stay dependent upon their individual needs. RESULTS: The distribution of patients by race was 504 whites, 115 blacks, 38 Hispanics, and 13 Asians. The mean age of the study population was 70 yrs. Whites had a higher prevalence of atrial fibrillation, and blacks, Hispanics, and Asians had a higher prevalence of hypertension and diabetes mellitus. The primary and secondary functional rehabilitation outcomes were similar for all four groups after similar intensity of therapy (3.5 hrs daily). CONCLUSIONS: This study suggests that race does not influence rehabilitation functional outcomes in patients with acute stroke undergoing rehabilitation for the same intensity of therapy if admitted soon after their acute stroke.

The epidemiology of pediatric patients seen at the Children's Hospital of Oklahoma with laboratory confirmed influenza in 2009.

CONTEXT: In 2009, a new strain of influenza A, subtype H1N1, infected otherwise healthy children with increased rate of hospitalization. STUDY OBJECTIVE: To document the type of influenza infection, identify those pediatric patients at risk for complications, compare those patients requiring hospital admission to those discharged, and examine the use of antiviral/antibiotic medications. METHODS: We conducted a retrospective chart review of patients 0-18 years, in 2009 that tested positive at Children's Hospital for influenza. Type of influenza, initial presentation, secondary complications, underlying co-morbidities, hospitalization, death, antiviral and antibiotic prescribing practices were recorded. RESULTS: Two hundred and eighty-seven patients tested positive. Two hundred and twelve were influenza A, H1N1 subtype, 55 were Influenza A, not subtyped and 20 were influenza B. One hundred and twenty-eight of our study patients were hospitalized (44%). One hundred and three patients were positive for H1N1, for a hospitalization rate of 47%, Fifteen percent of the study population required Intensive care support. Caucasian patients and those having chronic medical conditions were more likely to require hospitalization. Early antiviral therapy was associated with a better outcome. CONCLUSION: The majority of children with influenza in 2009 had the novel H1N1 strain. Almost half of study patients were hospitalized. Patients with underlying medical problems were more likely to be hospitalized. The majority of hospitalized patients had good outcomes.

Delineation of subtelomeric deletion of the long arm of chromosome 6.

Pure subtelomeric deletion of the long arm of chromosome 6 is rare. The frequency of this deletion accounts for approximately 0.05% of subjects with intellectual disability and developmental delay with or without dysmorphic features. Common phenotypes associated with this deletion include intellectual disability, developmental delay, dysmorphic features, seizure, hypotonia, microcephaly and hypoplasia of the corpus callosum. The smallest overlapped region is approximately 0.4 Mb, and contains three known genes. Of these genes, TBP has been considered as a plausible candidate gene for the phenotype in patients with a subtelomeric 6q deletion. Analysis of the breakpoints in 14 cases revealed a potential common breakpoint interval 8.0-9.0 Mb from the chromosome 6q terminus where the FRA6E fragile site exists and the PARK2 gene is located. This suggests that breakage at the FRA6E fragile site may be the mechanism behind chromosome 6q subtelomeric deletion in some of the cases.