Effects of delivery room quality improvement on premature infant outcomes.

OBJECTIVE: Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality. STUDY DESIGN: This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group. RESULTS: Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death. CONCLUSION: Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.

Prevention of Group B Streptococcus early-onset disease: a toolkit by the California Perinatal Quality Care Collaborative.

The California Perinatal Quality Care Collaborative (CPQCC) was organized in 1996 in an effort to improve perinatal outcomes in California. CPQCC has a robust infrastructure of quality improvement resources and expertise and uses a database of demographic and outcome data from neonatal intensive care units in California. In 2004, CPQCC developed a toolkit to provide an evidence-based framework and supporting documents for hospitals to use in systematically addressing persistent early-onset disease (EOD) because of Group B Streptococcus (GBS) in their centers. The CPQCC toolkit was based on the 2002 Centers for Disease Control guideline, 'Prevention of Perinatal Group B Streptococcal Disease.' This article presents an updated version of the CPQCC toolkit reflecting several population studies published since the 2002 guideline. Current epidemiological trends in incidence of EOD with GBS, changes in antibiotic sensitivity and the potential value of newer strategies are discussed.

Meconium aspiration syndrome remains a significant problem in the NICU: outcomes and treatment patterns in term neonates admitted for intensive care during a ten-year period.

OBJECTIVE: The purpose of this study was to evaluate the demographic and treatment characteristics of neonates (>or=37 weeks' estimated gestational age) who were admitted to a neonatal intensive care unit (NICU) for a diagnosis of meconium aspiration syndrome (MAS) during the years 1997 to 2007. The goals in studying this group of neonates were to better estimate the magnitude of abnormal outcomes and to determine the proportion of these infants exposed to specific therapeutic interventions. STUDY DESIGN: Retrospective review of an administrative de-identified data set. RESULT: A total of 415,772 neonates formed the starting data set and 162,075 (39%) were >or=37 weeks. Of the 162,075 term neonates, 7518 (1.8% of all neonates and 4.6% of term NICU admissions) had an admission diagnosis of MAS. In the 7518 neonates, the following outcomes were observed: 6124 (81.5%) were discharged home; 679 (9%) were acutely transferred to a higher level of intensive care; 416 (5.5%) were transferred to another clinical service within the hospital; 178 (2.4%) were transferred to another NICU for convalescent care and 88 (1.2%) died. There were 33 (0.4%) who did not have data on outcome at discharge. During the period between 2002 and 2005, acute transfer rates decreased (12.4 to 9%) and the reported rate for death remained relatively constant between 0.9 and 1.5%. There were 107 (1.4%) neonates who were treated (n=61) with, or transferred, for extracorporeal membrane oxygenation (ECMO) (n=46). Three of the sixty-one neonates (4.9%) who were treated with ECMO died. CONCLUSION: Term neonates who are admitted with a diagnosis of MAS continue to represent a high-risk population with significant morbidity, and they often require intensive therapies.

Randomized trial of long-term diuretic therapy for infants with oxygen-dependent bronchopulmonary dysplasia.

STUDY OBJECTIVE: To determine whether long-term oral diuretic therapy would improve the pulmonary function of preterm infants with bronchopulmonary dysplasia. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Level III intensive care nursery. INTERVENTION: We randomly selected 43 stable patients with oxygen-dependent bronchopulmonary dysplasia to receive either orally administered spironolactone and chlorothiazide or placebo. These drugs were continued until the patients no longer required supplemental oxygen. Both groups received furosemide as needed. MEASUREMENTS AND RESULTS: Each infant had pulmonary function tests at study entry, 4 weeks after study entry, 1 week and 8 weeks after being weaned to room air and off study drugs, and at 1 year of corrected age. Pulmonary function tests include dynamic pulmonary compliance, airway resistance, thoracic gas volume, and maximal expiratory flow at functional residual capacity; most of the infants had functional residual capacity measured. Between the first and second pulmonary function tests (while the infants were receiving diuretic or placebo), the infants in the diuretic group had a significant improvement in dynamic pulmonary compliance (46%; p < 0.001) and airway resistance (31%; p < 0.05); there were no changes in compliance or resistance in the placebo group. Although patients in both the diuretic and the placebo groups required progressively less supplemental oxygen, by 4 weeks after study entry the patients in the diuretic group needed less supplemental oxygen than did those in the placebo group (p < 0.01). There were no significant differences in results of serial pulmonary function tests in either group after discontinuation of diuretic therapy. Despite the significant differences in pulmonary function between the two groups, there was no significant difference between them in the total number of days that supplemental oxygen was required. Significantly more infantsin the placebo group received more than 10 doses of furosemide on an as-needed basis. CONCLUSIONS: Long-term diuretic therapy in stable infants with oxygen-dependent bronchopulmonary dysplasia, after extubation, improves their pulmonary function and decreases their fractional inspired oxygen requirement, but does not decrease the number of days that they require supplemental oxygen. The improvement in pulmonary function associated with diuretic therapy is not maintained after treatment is discontinued.

Adrenal calcification and congenital nephrotic syndrome in three American Indians.

Two Pima and one Papago Indian infants with congenital nephrosis and adrenal calcifications are described. All developed anasarca early and none had an explanation for the adrenal calcification.

Atypical endogenous opioid systems in mice in relation to an auto-addiction opioid model of anorexia nervosa.

We have proposed that the atypical opioid system in the mouse may be representative of that in the anorexia nervosa patient and may account for a biological predisposition to the disorder. This is in the context of our auto-addiction model of anorexia nervosa in which endogenous opioids play a critical role in its etiology. Morphine activation of the endogenous opioid systems increases food intake and causes sedation in most species, including normal humans and rats. In contrast in BALB/C mice, morphine causes anorexia and hyperactivity, which we suggest may be true in the anorexia nervosa patient. A variety of atypical opioid systems have been demonstrated in different mouse strains, based on other responses. The present study examines these strains with reference to the responses relevant to our anorexia nervosa model. Three patterns are described--anorexia with hyperactivity (BALB/C and C57BL/6J mice), anorexia without hyperactivity (DBA/J mice), and a biphasic curve with hyperphagia at low doses and anorexia and hyperactivity at higher doses (CF-1 mice). Only female mice were used. These atypical opioid systems may reflect a spectrum of biological predispositions to the disorder. These strain differences may also provide useful correlations of the genetic determinants of various opiate responses and provide useful comparisons in characterizing the essential features responsible for the atypical responses.

Stress and alcohol.

Alcohol's role in the relief of stress is reviewed. Limitations are observed in recent studies of alcohol and stress. Where stress has been viewed as synonymous with anxiety or tension, many potential stressors and stress responses have been unaccounted for or ignored. Stress is distinguished from tension and anxiety, and a "stress reduction hypothesis" of alcohol abuse is suggested in place of the recently prominent "tension reduction hypothesis." Alcohol has been found to be a frequent contributor to increased stress. Stress-relief drinking is concluded to be one of several prominent factors in the etiology of alcohol abuse and dependency. Suggestions are made for research and treatment.

Hepatitis B virus in patients undergoing hemodialysis: transmission risks and psychosocial reactions.

Thirteen patients undergoing hemodialysis who were carriers of hepatitis B virus (HBV) were screened for inappropriate reactions to HBV transmission risks and for emotional reactions to their renal and viral diseases. Four patients underreacted to HBV transmission risks through denial or misunderstanding. The nine remaining patients reported that their HBV, as compared with their renal disease, resulted in substantially greater restrictions in interpersonal relations and significantly greater feelings of not being accepted by others. In contrast, the nine patients reported that their renal disease, as compared with their HBV, resulted in substantially greater restrictions in leisure and work activities. Thirteen control patients undergoing hemodialysis but not having HBV did not differ from the patients with HBV in psychosocial reactions to renal disease. As shown in a one-month follow-up, counseling was effective in enhancing awareness of HBV transmission risks and in improving emotional adjustments to the renal and viral diseases.

Alternate approach to the management of acute perforating appendicitis in children.

The results of this study support the conservative management of acutely ill patients with the clinical diagnosis of perforating appendicitis. An interval appendectomy should be performed four to six weeks later. If the patient does not respond after a clinical trial of 12 to 24 hours, there is no increased morbidity from performing an appendectomy at that time. Selection of antibiotic therapy should be appropriate to cover the usual intestinal flora of aerobes and anaerobes. Ampicillin, gentamycin or tobramycin, and clindamycin currently are the recommended antibiotics at this institution. The patient is seen in the office each week until interval appendectomy is performed. Any recurrence of fever or abdominal pain warrants immediate hospital admission and appendectomy. This approach in selected patients had proved safe when adequate follow-up study is assured.

Hepatitis B virus. Inappropriate reactions to transmission risks.

Ten patients designated as hepatitis B surface antigen (HBsAg) carriers were screened for inappropriate reactions to their disease. Assessment with a 32-item questionnaire showed three carriers to have underreacted to the risks of HBsAg transmission through misunderstandings or denial concerning the disease. One carrier, through severe social withdrawal, showed overreaction to the possibilities of disease transmission. Counseling was provided regarding the risks of HBsAg transmission. At a one-month follow-up, all carriers appeared appropriately aware of the risks of transmission, and one of two carriers referred for psychotherapy showed greatly improved social adjustment. We recommend that persons treating HBsAg carriers screen routinely for inappropriate reactions to risks of disease transmission and provide counseling as needed.