Development of a Multidisciplinary Medical Home Program for NICU Graduates.

OBJECTIVE: Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population. METHODS: This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs. RESULTS: The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down. DISCUSSION: Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Association between hemoglobin concentrations at discharge from the neonatal intensive care unit with markers of neurodevelopmental outcomes in premature neonates.

BACKGROUND: Premature neonates are often subjected to multiple transfusions with red blood cells during their hospitalization in the neonatal intensive care unit (NICU). The hemoglobin threshold for transfusion prior to discharge from the NICU varies significantly among different centers. The aim of the present study is to investigate the association between hemoglobin concentration at discharge with neurodevelopmental outcomes in premature neonates. METHODS: Retrospective observation study with regression analysis was performed with follow up assessment in the neuro-developmental outpatient clinic at 30 months of adjusted age. RESULTS: Data from 357 neonates born at less than 37 weeks' gestation were analyzed. Sensory and motor neurodevelopment at 30 months of adjusted age, were not associated with the hemoglobin concentration at discharge (p=0.5891 and p=0.4575, respectively). There was no association between the hemoglobin concentration at discharge with fine or gross motor development (p=0.1582 and p=0.3805, respectively). Hemoglobin concentration at discharge was not associated with poor neurodevelopmental outcomes up until 30 months of adjusted age. CONCLUSIONS: The data of the present study indicate that the hemoglobin concentration of premature neonates at the time of discharge is not associated with poorer markers of neurodevelopmental outcomes at 30 months of adjusted age. Comorbidities such as BPD and IVH that are present to premature neonates were identified as potential risk factors for certain aspects of the neurodevelopment.

Transition to Routine Premedication for Nonemergent Intubations in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: This study aims to test whether implementing a guideline for nonemergent intubation improves the rate of premedication for nonemergent intubations in an academic level IV neonatal intensive care unit (NICU). We further sought to test the hypothesis that neonates who receive premedication for a nonemergent intubation have decreased pain scores at the time of intubation, fewer intubation attempts, and no associated adverse events. STUDY DESIGN: This was a prospective observational study with ongoing audit and feedback as well as statistical process control analysis. Data collection began on October 1, 2014. Clinical guideline implementation began in October 2015. A percent "P"-chart spanning seven-quarters was constructed with statistical process control analysis plotting premedication rates over time. Student's t-tests or Wilcoxon rank-sum tests were used for secondary outcomes. RESULTS: The mean number of nonemergent intubations given premedications increased from 34 to 82%. The mean pain score was lower when premedications were given: 0.34 (95% confidence interval [CI]: 0.10-0.58) versus 2.8 (95% CI: 1.9-3.6) (p < 0.001). The number of intubation attempts did not differ with premedications. CONCLUSION: Adopting a guideline with supporting educational initiatives to standardize premedication before nonemergent intubations increased this practice. This regimen lowered clinical pain scores with no difference in the number of intubation attempts.

Language development survey provides a useful screening tool for language delay in preterm infants.

Developmental language disorder has been reported in 3% to 10% of term infants and 30% of preterm infants (<34 weeks gestation). Screening for language delay in preterm infants can be costly and time-consuming. The objective of this study was to assess the expressive language development of preterm infants using the Language Development Survey (LDS). A total of 178 preterm infants born at 23 to 34 weeks between 2006 and 2008 were enrolled. The LDS was completed by parents between 22 and 26 months at or shortly before 2-year neurodevelopmental assessment using the Bayley III Scale. A total of 26% of former preterm patients had language delay, using LDS. Significant correlations were observed between LDS results and Bayley III scores. Male gender and public health insurance were the most important risk factors for language delay in this cohort. Expressive language delay was present in 26% of preterm infants. LDS is a suitable and inexpensive screening tool for assessing language delay in preterm infants.

Characterization of a novel isoform of alpha-nascent polypeptide-associated complex as IgE-defined autoantigen.

The nascent polypeptide-associated complex is required for intracellular translocation of newly synthesized polypeptides in eukaryotic cells. It may also act as a transcriptional coactivator in humans and various eukaryotic organisms and binds to nucleic acids. Recently, we provided evidence that a component of nascent polypeptide-associated complex, alpha-nascent polypeptide-associated complex, represents an IgE-reactive autoantigen for atopic dermatitis patients. By oligonucleotide screening we isolated a complete cDNA coding for a so far unknown alpha-nascent polypeptide-associated complex isoform from a human epithelial cDNA library. Southern blot hybridization experiments provided further evidence that alpha-nascent polypeptide-associated complex is encoded by a gene family. Recombinant alpha-nascent polypeptide-associated complex was expressed in Escherichia coli as a soluble, His-tagged protein, and purified via nickel affinity chromatography. By circular dichroism analysis it is demonstrated that purified recombinant alpha-nascent polypeptide-associated complex represents a folded protein of mixed alpha-helical and beta-sheet conformation with unusual high thermal stability and remarkable refolding capacity. Complete recombinant alpha-nascent polypeptide-associated complex (215 amino acids) and its 86 amino acid C-terminal fragment specifically bound IgE autoantibodies. Recombinant alpha-nascent polypeptide-associated complex also inhibited IgE binding to natural alpha-nascent polypeptide-associated complex, demonstrating the presence of common IgE epitopes between the recombinant and natural protein. Furthermore, recombinant alpha-nascent polypeptide-associated complex induced specific lymphoproliferative responses in peripheral blood mononuclear cells of a sensitized atopic dermatitis patient. As has been proposed for environmental allergens it is possible that T cell responses to IgE-defined autoantigens may contribute to the chronic skin manifestations in atopic dermatitis.