Neonatal respiratory care practice among level III and IV NICUs in New England.

OBJECTIVES: To assess respiratory care guidelines and explore variations in management of very low birth weight (VLBW) infants within a collaborative care framework. Additionally, to gather clinical leaders' perspectives on guidelines and preferences for ventilation modalities. STUDY DESIGN: Leaders from each NICU participated in a practice survey regarding the prevalence of unit clinical guidelines, and management, at many stages of care. RESULTS: Units have an average of 4.3 (±2.1) guidelines, of 9 topics queried. Guideline prevalence was not associated with practice or outcomes. An FiO2 requirement of 0.3-0.4 and a CPAP of 6-7 cmH2O, are the most common thresholds for surfactant administration, which is most often done after intubation, and followed by weaning from ventilatory support. Volume targeted ventilation is commonly used. Extubation criteria vary widely. CONCLUSIONS: Results identify trends and areas of variation and suggest that the presence of guidelines alone is not predictive of outcome.

Evaluation of lung volumes and gas exchange in surfactant-deficient rabbits between variable and fixed servo pressures during high-frequency jet ventilation.

OBJECTIVE: To investigate a novel servo pressure (SP) setting during high-frequency jet ventilation (HFJV) for a lung protective strategy in a neonatal model of acute respiratory distress. STUDY DESIGN: Comparison of efficacy between variable (standard) and fixed SP settings in a randomized animal study using rabbits (n = 10, mean weight = 1.80 kg) with surfactant deficiency by repeated lung lavages. RESULTS: Rabbits in the fixed SP group had greater peak inspiratory pressure, SP, minute volume, pH, and PaO2, and lower PaCO2 after lung lavage than the variable SP group. Lung volume monitoring with electrical impedance tomography showed that fixed SP reduced the decline of the global lung tidal variation at 30 min after lung lavage (-17.4% from baseline before lavage) compared to variable SP (-44.9%). CONCLUSION: HFJV with fixed SP significantly improved gas exchange and lung volumes compared to variable SP. Applying a fixed SP may have important clinical implications for patients receiving HFJV.

Humanitarian action in academic institutions: a case study in the ethical stewardship of unidentified forensic cases.

Forensic anthropologists are often responsible for the management of long-term unidentified individuals. Others have contextualised these decedents-many of whom likely belonged to socially, politically, and/or economically marginalised groups in life-as part of a larger identification crisis in the US. However, there has been little discussion surrounding how this humanitarian crisis has manifested in academic institutions, where anthropologists often provide medicolegal consultation and act as long-term stewards of the unidentified. The Identification & Repatriation Initiative was created at the Forensic Anthropology Centre at Texas State University (FACTS) to recognise and investigate unidentified human remains in long-term storage. Our paper outlines common challenges that were encountered during our initial reassessment of unidentified cases at FACTS, emphasising the detrimental impacts of inconsistent procedures, loss of context, and case fatigue. It is likely that other academic institutions face similar challenges, and by highlighting these issues we hope to help initiate a larger conversation concerning ethical stewardship of human remains in these settings. By incorporating humanitarian perspectives into forensic casework, anthropologists in academia can better advocate for the long-term unidentified.Key pointsForensic anthropologists at academic institutions are qualified to act as consultants on forensic casework when requested by jurisdictional authorities and are often responsible for the long-term management of unidentified human remains.The long-term unidentified represent a vulnerable population and academic institutions are not exempt from calls for humanitarian approaches to identification.The Identification and Repatriation Initiative was created at the Forensic Anthropology Centre at Texas State University to acknowledge and investigate unidentified human remains in long-term storage.This paper considers possible ways for humanitarian action to be incorporated into academic settings and suggests anthropologists can better advocate for the unidentified through procedural standardisation, institutional and interagency collaboration and ethical stewardship.

Elemental composition of primary lamellar bone differs between parous and nulliparous rhesus macaque females.

Extracting life history information from mineralized hard tissues of extant and extinct species is an ongoing challenge in evolutionary and conservation studies. Primary lamellar bone is a mineralized tissue with multidien periodicity that begins deposition prenatally and continues until adulthood albeit with concurrent resorption, thus maintaining a record spanning several years of an individual's life. Here, we use field-emission scanning electron microscopy and energy-dispersive X-ray analysis to measure the relative concentrations of calcium, phosphorous, oxygen, magnesium and sodium in the femora of seven rhesus macaque with known medical and life-history information. We find that the concentration of these elements distinguishes parous from nulliparous females; that in females calcium and phosphorus are lower in bone formed during reproductive events; and that significant differences in relative magnesium concentration correlate with breastfeeding in infants.

The Effects of Experimental Whole-Body Burning on Histological Age-at-Death Estimation from Human Cortical Bone and Dental Cementum.

Whole-body donations (n = 6) were placed in various experimental fire-death scenarios to understand the histological effects of thermal alteration on bones and teeth. Midshaft samples of the femur, 6th rib, and metatarsal were removed from each donor pre- and post-burning to examine histomorphometric differences and test established age-at-death estimation methods. Dental samples were taken post-burning to test the applicability of dental cementum analysis for age-at-death estimation. Significant differences in osteon area or Haversian canal area between some pre- and post-burn samples were found although no patterns related to temperature or element were observable. The femoral age estimates across pre- and post-burn samples were 91% accurate across all donors. The point age estimates from the ribs compared to known age were significantly different (t(10) = 6.88, p < 0.001) with an average difference of −18.53 years. Dental age estimates of post-burn samples were not significantly different from the known donor age (t(3) = −0.74, p = 0.512) with an average difference of −3.96 years. Overall, the results of this study show that thermally altered remains can be used for histologic age-at-death analysis of cortical bone and dental cementum, within certain burning parameters.

Quality improvement for neonatal resuscitation and delivery room care.

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

Quality Improvement for Neonatal Resuscitation and Delivery Room Care.

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

Providing Support for Neonatal Intensive Care Unit Health Care Professionals: A Bereavement Debriefing Program.

OBJECTIVE: The aim of this study is to evaluate formal bereavement debriefing sessions after infant death on neonatal intensive care unit (NICU) staff. STUDY DESIGN: Prospective mixed methods study. Pre- and postbereavement debriefing intervention surveys were sent to clinical staff. Evaluation surveys were distributed to participants after each debriefing session. Notes on themes were taken during each session. RESULTS: More staff attended sessions (p < 0.0001) and attended more sessions (p < 0.0001) during the postdebriefing intervention epoch compared with the predebriefing epoch. Stress levels associated with the death of a patient whose family the care provider have developed a close relationship with decreased (p = 0.0123). An increased number of debriefing session participants was associated with infant age at the time of death (p = 0.03). Themes were (1) family and provider relationships, (2) evaluation of the death, (3) team cohesion, (4) caring for one another, and (5) emotional impact. CONCLUSION: Bereavement debriefings for NICU staff reduced the stress of caring for dying infants and contributed to staff well-being. KEY POINTS: · Providing end-of-life care in NICU is challenging.. · Debriefings assist staff in coping with grief.. · Staff well-being impacts patient care..

Self-reported levels of occupational stress and wellness in forensic practitioners: Implications for the education and training of the forensic workforce.

While there is extensive research into wellness and mental health risks for police officers and other first responders, a smaller portion of research has considered how forensic practitioners are affected. This study surveyed 211 forensic practitioners from the American Academy of Forensic Sciences membership, the Clark County Office of the Coroner/Medical Examiner, and the New York City Office of Chief Medical Examiner to assess current wellness perceptions within forensics. The 22-question survey focused on (a) how the demands of daily casework affect self-perceived burnout levels, (b) whether mental health issues are adequately addressed during the education and training of the forensic workforce, and (c) whether forensic professionals are getting the wellness support that they themselves feel that they need. Basic descriptive statistics, chi-square (χ2 ) cross tabulations, and correlation analyses were constructed to assess relevant relationships within survey responses. Results indicate that forensic professionals report a high level of burnout and a lack of sufficient wellness resources in their current professional climate. While professionals feel fulfilled from their work, the majority of respondents (73.9%) felt that common mental health issues that exist in their profession were not adequately addressed during their workplace training, academic schooling, or professional certification. Despite the uniformly weak correlations observed between variables, chi-square analyses reveal practically and statistically significant trends that warrant further investigation, particularly in the context of vicarious trauma. Overall, this study provides an important baseline for future wellness research to support the specialized needs of forensic scientists during their training and education.

Ambient Noise Production by High-Frequency Neonatal Ventilators.

OBJECTIVE: To assess sound levels of 4 high-frequency neonatal ventilators to determine whether there is a safety benefit in using modern high-frequency ventilators compared with older models. STUDY DESIGN: We performed a bench study comparing noise production of the Sensormedics 3100A Oscillator, Bunnell Life Pulse Jet Ventilators Model 203 and Model 204, and Dräger VN500 in high-frequency mode. A wide range of ventilation settings was examined. All measurements were performed in triplicate using a high-fidelity sound meter, with data analyzed using ANOVA and regression analyses. RESULTS: The Dräger ventilator was quietest overall, with average sound levels of 49.8 ± 0.49 dB across all settings. The average noise from the Sensormedics was 53.6 ± 2.01 dB, for Bunnell Model 203 was 54.1 ± 1.09 dB, and for Bunnell Model 204 was 53.7 ± 1.45 dB. Adjustments made to frequency/rate and mean airway pressure/positive end-expiratory pressure had minimal effect on noise, and increasing amplitude/peak inspiratory pressure resulted in significantly more noise by all ventilators. At all settings, the Sensormedics and Bunnell ventilators were louder than the Dräger, and the difference became greater as amplitude/peak inspiratory pressure was increased. CONCLUSIONS: The Dräger VN500 in high-frequency mode produces significantly less noise that both the Sensormedics and Bunnell ventilators. These data suggest that using the Dräger VN500 as a high-frequency ventilator may reduce the potential for adverse outcomes created by ventilator noise.

Occult Massive Visceral Fat Necrosis Following Therapeutic Hypothermia for Neonatal Encephalopathy.

Therapeutic hypothermia (head or whole-body cooling) improves survival and neurodevelopmental outcome in term newborns with moderate-to-severe encephalopathy. Hypothermia treatment is well tolerated; the most common side effect is thrombocytopenia. In about 1% of infants, focal subcutaneous fat necrosis has been reported. We describe a case of clinically unsuspected massive visceral fat necrosis in a term infant with Apgar score 0 at 1 min ("resuscitated apparently stillborn" infant) who was treated with therapeutic hypothermia for 72 h and expired on the 25th day of life following a neonatal course complicated by severe encephalopathy, pulmonary artery hypertension, persistent thrombocytopenia, hypoglycemia, and severe basal ganglia-thalamic abnormalities on magnetic resonance imaging. Postmortem examination revealed extensive visceral (brown) fat necrosis, involving thoracic, abdominal, and retroperitoneal adipose tissue, with distinctive sparing of the subcutaneous (white) fat. The fulminant-yet clinically occult-visceral fat necrosis seen in this case suggests that (lesser degrees of) fat necrosis may go unrecognized in hypoxic-ischemic newborns, especially in those treated with hypothermia, and underscores the importance of close monitoring of encephalopathic newborns both in the short and long terms for complications of fat necrosis (hypercalcemia and nephrocalcinosis).