Building a NICU quality & safety infrastructure.

The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards.

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates.

OBJECTIVE: To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation. DESIGN: Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS). SETTING: Eighteen academic NICUs in NEAR4NEOS. PATIENTS: Neonates requiring two or more attempts at intubation between October 2014 and December 2021. MAIN OUTCOME MEASURES: The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice. RESULTS: 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs. CONCLUSIONS: Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.

Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication.

Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.

Update on the state of research to manage Fusarium head blight.

Fusarium head blight (FHB) is one of the most devastating diseases of cereal crops, causing severe reduction in yield and quality of grain worldwide. In the United States, the major causal agent of FHB is the mycotoxigenic fungus, Fusarium graminearum. The contamination of grain with mycotoxins, including deoxynivalenol and zearalenone, is a particularly serious concern due to its impact on the health of humans and livestock. For the past few decades, multidisciplinary studies have been conducted on management strategies designed to reduce the losses caused by FHB. However, effective management is still challenging due to the emergence of fungicide-tolerant strains of F. graminearum and the lack of highly resistant wheat and barley cultivars. This review presents multidisciplinary approaches that incorporate advances in genomics, genetic-engineering, new fungicide chemistries, applied biocontrol, and consideration of the disease cycle for management of FHB.

Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach.

Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.

Biofilm Formation and Structure in the Filamentous Fungus Fusarium graminearum, a Plant Pathogen.

Biofilms are protective structures for pathogens of plants and animals, in which cells are shielded from host defense responses and antimicrobial treatments. Although biofilms are well studied in bacterial pathogens, their development and structure in filamentous fungi, as well as their role in pathogenicity, are poorly understood. We show that the economically important plant pathogen Fusarium graminearum, a filamentous fungus, forms biofilms in vitro, which adhere to polystyrene, a hydrophobic surface. The biofilms have complex hyphal structures surrounded by a polymeric matrix that consists primarily of polysaccharides and extracellular nucleic acids, and lack lipids. Pellicles are formed in liquid cultures, floating biofilm masses that are common in bacterial biofilms, and noted but undescribed in filamentous fungal biofilms. Commonly, F. graminearum grows as hyphal colonies; however, on media which lack electron acceptors, an altered morphology is formed with predominantly short, bulbous hyphae embedded in the matrix. Supplementation of the biofilm-inducing medium with an electron acceptor restores the filamentous hyphal morphology, demonstrating that the formation of bulbous hyphae is due, at least in part, to oxidative stress. Plant hosts infected with pathogens generally respond by producing reactive oxygen species, commonly produced as a defense response. Thus, the formation of biofilms strongly suggests a role in protecting cells from host responses during the course of plant disease. IMPORTANCE Fusarium graminearum is a filamentous fungal pathogen that causes Fusarium head blight (FHB) in cereal crops, leading to devastating crop losses. We have demonstrated the ability of this pathogen to form biofilms. Biofilms are likely to be important in the disease cycle of F. graminearum and other plant pathogens, protecting cells from plant defenses and environmental conditions. Towards this end, we have characterized the formation of biofilms in F. graminearum in vitro, which, together with ongoing characterization of their association with host plants, provides a basis for understanding the functionality of biofilms in the pathogen disease cycle.

Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes.

OBJECTIVE: We sought to standardize and improve compliance with evidence-based premedication for non-emergent neonatal intubations in two academic-affiliated Neonatal Intensive Care Units. STUDY DESIGN: A multidisciplinary team created guidelines and electronic medical record order sets for intubation. Compliance with recommended premedication, number of intubation attempts, and frequency of bradycardia and desaturation were assessed. RESULTS: 387 intubation procedures were reviewed. Provision of recommended premedication increased by 36% and 75% at the level III and IV units, respectively. Decreased frequency of bradycardia during intubation (p = 0.0003) occurred in the level III unit. A reduction in number of intubation attempts (p ≤ 0.001), improvement in first-attempt intubation success (p ≤ 0.001), and decreased frequency of bradycardia (p = 0.01) and desaturation (p = 0.02) during intubation occurred in the level IV unit. CONCLUSIONS: This quality improvement initiative improved standardized premedication compliance and decreased adverse events associated with non-emergent neonatal intubations in two separate units.

A Pediatric Resident Safety Council: A Framework for Developing Quality and Safety Leadership.

Quality improvement (QI) and patient safety are essential to the practice of medicine. Specific training in these fields has become a requirement in graduate medical education, although there is great variation in how residency programs choose to approach trainee education in QI and patient safety. Residents have a unique vantage point into the operations of a health care system and can guide the development of system improvement initiatives. In this report, we (1) describe the context that led to the creation of a pediatric resident safety council (PRSC) in its current structure, (2) identify the organizational features implemented to best meet the objectives of this council, and (3) describe the local and institutional impact of the PRSC. A PRSC is a useful model to build resident engagement in safe and high-quality patient care within a residency program and health care system. A PRSC encourages the professional development of future pediatric safety leaders and facilitates experiential training in patient safety and QI science.

A Cost-Effectiveness Analysis of Nivolumab Plus Ipilimumab Versus Pembrolizumab Plus Axitinib and Versus Avelumab Plus Axitinib in First-Line Treatment of Advanced Renal Cell Carcinoma.

BACKGROUND: There now exist several viable first-line treatment options for metastatic renal cell carcinoma, making the choice of initial therapy difficult. Considering metrics other than patient factors may be necessary to select the most appropriate therapy. We aimed to assess the cost-effectiveness of the three combination therapies currently approved in treatment-naïve advanced or metastatic renal cell carcinoma-nivolumab + ipilimumab (NI), pembrolizumab + axitinib (PA), and avelumab + axitinib (AA)-from a US payer perspective. PATIENTS AND METHODS: Our analysis was performed based on previously obtained data derived from progression-free survival and overall survival curves from CheckMate 214, KEYNOTE 426, and JAVELIN Renal 101. RESULTS: The total costs of each treatment were found to be $437,556.12 for NI, $450,597.15 for PA, and $542,882.34 for AA, with quality-adjusted life-year (QALY) values of 4.04, 3.77, and 2.95 for each combination, respectively. The incremental cost-effectiveness ratio (ICER) of NI versus PA was ($47,504.73/QALY); for NI versus AA, it was ($96,533.11/QALY); for PA versus AA, it was ($113,015.87/QALY). Net health benefit scaled against a willingness-to-pay threshold of $150,000 per QALY was positive for NI versus PA at 0.36 and versus AA at 1.79, and this index was also positive for PA versus AA at 1.43, indicating that the additional value of these therapies versus their alternatives is greater than the extra cost. CONCLUSION: NI was found to be the most cost-effective treatment option compared with the other considered therapies. PA was found to be cost effective compared to AA. When patient factors such as social issues and pre-existing conditions do not dictate their first-line therapy, clinicians may use this additional information to make financially conscious choices.

Paraneoplastic Encephalitis Associated with Locally Advanced Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer.

Paraneoplastic neurologic diseases (PND) are rare but can occur in patients with common malignancies including breast cancer. In patients with hormone receptor (HR)-negative human epidermal growth factor receptor 2 (HER2)-positive breast cancer, PND have been reported in association with anti-Yo antibodies and with clinical presentation of paraneoplastic cerebellar degeneration. We describe the case of a woman with progressively altered mental status and seizures, ultimately requiring admission. Based on her clinical presentation, imaging findings, and evidence of neural-directed antibodies in her serum and cerebrospinal fluid, she was diagnosed with paraneoplastic limbic encephalitis (LE) due to an underlying HR-negative, HER2-positive breast cancer. She showed a transient response to immunosuppression but had more significant improvement after surgical resection and initiation of chemotherapy along with HER2-directed therapy. To the best of our knowledge, this is the first documented case of paraneoplastic LE in a patient with HR-negative, HER2-positive breast cancer likely caused by the production of an unclassified anti-neuronal antibody.