Cara Geary

Decreased incidence of bronchopulmonary dysplasia after early management changes, including surfactant and nasal continuous positive airway pressure treatment at delivery, lowered oxygen saturation goals, and early amino acid administration: A historical cohort study

OBJECTIVE. The goal was to investigate the clinical impact of 3 early management practice changes for infants of ≤1000 g. METHODS. We performed an historical cohort study of appropriately sized, preterm infants without congenital anomalies who were born between January 2001 and June 2002 (pre–early management practice change group; n = 87) and between July 2004 and December 2005 (post–early management practice change group; n = 76). RESULTS. Only 1 (1%) of 87 infants in the pre–early management practice change group received continuous positive airway pressure treatment in the first 24 hours of life, compared with 61 (80%) of 76 infants in the post–early management practice change group. The proportions of infants who required any synchronized intermittent mandatory ventilation during their hospital stays were 98.8% and 59.5%, respectively. The mean durations of synchronized intermittent mandatory ventilation were 35 days and 15 days, respectively. The combined incidence rates of moderate and severe bronchopulmonary dysplasia at corrected gestational age of 36 weeks were 43% and 24%, respectively. The use of vasopressor support for hypotension in the first 24 hours of life decreased from 39.1% (before early management practice changes) to 19.7% (after practice changes), the cumulative days of oxygen therapy decreased from 77 ± 52 days to 56 ± 47 days, and the proportions of infants discharged with home oxygen therapy decreased from 25.7% to 10.1%; the incidence of patent ductus arteriosus requiring surgical ligation increased from 1% to 10%.There were no differences in rates of death, intraventricular hemorrhage, periventricular leukomalacia, pneumothorax, necrotizing enterocolitis, or retinopathy of prematurity. CONCLUSIONS. Successful early management of extremely preterm infants with surfactant treatment followed by continuous positive airway pressure treatment at delivery, lowered oxygen saturation goals, and early amino acid supplementation is possible and is associated with reductions in the incidence and severity of bronchopulmonary dysplasia.

Sustained impact of MBSR on stress, well-being, and daily spiritual experiences for 1 year in academic health care employees.

OBJECTIVES The objectives of the study were (1) to evaluate self-reported stress levels and daily spiritual experiences in academic health care employees before, immediately after, and 1 year after enrolling in a mindfulness-based stress reduction (MBSR) course; and (2) to evaluate the correlation between a potential measure of pulse rate variability and self-reported stress levels. SUBJECTS Fifty-nine (59) participants in the MBSR course offered to employees at the University of Texas Medical Branch in Galveston (UTMB) comprised the intervention group, and 94 health care providers in the neonatal nurseries comprised the control group. INTERVENTION MBSR is an 8-week course that introduces mindfulness meditation practices. No intervention was offered to the control group. All participants were employees (or relatives of employees) at UTMB. DESIGN All MBSR participants completed Cohens Perceived Stress Scale, the SCL-90, the SF-36 Measure of Health and Well-Being, the Daily Spiritual Experiences Scale, and a 5-minute measure of pulse rate coherence. This testing was done before and after the MBSR course and 1 year later. Ninety-four (94) neonatal health care providers completed the same series of questionnaires and pulse rate variability (PRV) measures, with 49 of the 94 completing the questionnaires 2 months and 1 year later. RESULTS MBSR participants improved on all measures except the physical component score of the SF-36 upon completion of the MBSR course, and these results were maintained at the 1-year follow-up. The control group did not significantly change on any of the measures. PRV as measured by the Heart Math system did not correlate with any of the self-report questionnaires. CONCLUSIONS MBSR effectively reduces self-report measures of stress and increases daily spiritual experiences in employees in an academic health care setting, and these effects are stable for at least 1 year. Using a simple measure of PRV was not a clinically reliable biologic measure of stress.

Improved growth and decreased morbidities in <1000 g neonates after early management changes.

Objective:To test the hypothesis that three changes in the early management of extremely low birth weight (ELBW) neonates would decrease the incidence of extra-uterine growth restriction (EUGR) by 25%. The three early management practice changes (EMPC) included surfactant at delivery followed by immediate extubation to nasal continuous positive airway pressure (CPAP), decreased oxygen exposure and early parenteral amino acids.Study Design:Historical cohort study of preterm infants ⩽1000 g birth weight (BW) born at the University of Texas Medical Branch between January 2001 and June 2002 (pre-EMPC, before changes, n=87) and July 2004 to December 2005 (post-EMPC, after changes, n=76). Outcomes measured included feeding and growth parameters, morbidities and interventions. Statistical analysis included χ2-analysis, Students t-test, and analysis of variance.Result:Infants in the post-EMPC cohort regained BW more quickly, maintained appropriate size for weight at 36 weeks and had less morbidity associated with poor long-term outcome. Predictors of EUGR included BW <750 g and surgical necrotizing enterocolitis.Conclusion:The introduction of surfactant at delivery followed by immediate extubation to CPAP, decreased oxygen exposure and early parenteral amino acids in ELBW infants is possible, safe and associated with improvements in growth and morbidity.

Impact of providing vitamin A to the routine pulmonary care of extremely low birth weight infants.

Objective. The objective of this study was to determine if the continued use of vitamin A in a nursery utilizing early surfactant and nasal continuous positive airway pressure (CPAP) was warranted. Study design. A retrospective, cohort study of appropriately sized, preterm neonates weighing ≤1000 g at birth was conducted. Two time periods were compared: Pre-Vitamin A was composed of extremely low birth weight who were routinely cared for with early nasal CPAP (n = 76); and Post-Vitamin A (n = 102) consisted of ELBWs who were cared for similar to Pre-Vitamin A, but with the addition of vitamin A. Outcome variables included the incidence of BPD and other pulmonary and major neonatal morbidities. Results. Between Pre-Vitamin A and Post-Vitamin A the incidence of moderate to severe BPD decreased by 11%, from 33% to 22% (p = 0.2). No difference was found in the number of ventilator days or in the incidence of any other neonatal morbidity or mortality, including intraventricular hemorrhage, necrotizing enterocolitis, or patent ductus arteriosus requiring surgical ligation. Conclusion. In a neonatal unit utilizing early surfactant followed by nasal CPAP at delivery, supplementing extremely premature neonates with vitamin A demonstrated a trend towards a decrease in the incidence of moderate to severe BPD; however, this change requires a larger sample to verify in the future.

Parathyroid hormone levels in neonates with suspected osteopenia.

The goal of this study is to describe secondary hyperparathyroidism in extremely low birthweight (ELBW) neonates and their response to enteral calcium carbonate (CaCO3) supplementation.

Persistence of müllerian duct structures in a genetic male with distal monosomy 10q.

Persistent müllerian duct syndrome (PMD) with antimüllerian hormone (AMH) deficiency is usually associated with mutations or deletions of the AMH gene, although many cases have no identified gene association. We report on a genetic male with PMD and AMH deficiency associated with distal monosomy 10q. A term 3,230 g infant was born to a healthy 27‐year‐old. Fetal ultrasound had shown possible genital ambiguity. Postnatal exam showed a 0.5 cm phallus with basal meatus, normal scrotum with no palpable gonads, no vaginal orifice, and a rectal fistula with an imperforate anus. Voiding cystourethrogram with ultrasound, cystoscopy, and laparoscopy showed normal bladder, urethral orifice, distal vagina, cervix, and bilateral abdominal testis. At 24 hours of life, testosterone was within normal range with low AMH level. Chromosome microarray analysis showed 46, XY, del10(10q25.3q26.13) involving an 8.2 MB interstitial deletion. Whole exome sequencing identified a NOTCH2 variant (1p11.2). AMH sequencing revealed no abnormalities. Following multidisciplinary team and parent discussion, male gender was assigned. Testosterone treatment resulted in penile length of 1.5 cm. Bilateral orchiopexy and posterior sagittal anorectoplasty were performed at 11 months of age; rudimentary müllerian structures were identified. This observation suggests an association of 10qter elements with male differentiation including AMH expression and is similar to a patient with 46, XY, del(10q26.1) in which AMH levels were not reported. Regional candidate genes include FGFR2 (10q26.13). The possible contribution of a NOTCH2 variant cannot be excluded.

Neonatal parotid gland enlargement: Is it suppurative parotitis? a case report

Summary Background: Acute suppurative parotitis (ASP) is a rare finding in the neonate. It is commonly caused by S. aureus but other bacterial isolates may be emerging. Effective treatment includes prompt diagnosis, parenteral antibiotics and supportive measures such as rehydration and bimanual gland massage. Case Report: This case report describes an extremely premature female infant with a complicated post-natal course who presented with unilateral swelling of the parotid region. Diagnostic workup revealed purulent exudate from Stensen’s duct and ultrasound findings consistent with parotitis. Culture of the exudate showed growth of Staphylococcus aureus and Enterococcus species. The patient responded well to a ten-day antibiotic course and supportive measures. Conclusions: ASP, though rare, should be considered in the differential diagnosis of a neonatal parotid swelling since early and prompt diagnosis prevents morbidity and complications.

Bridging the compassion and empathy gap in medical school: the physician healer track at UTMB-Health.

Excellence in compassion and empathy require repeated practice. Instead of providing this practice, medical school curriculums emphasize data acquisition and regurgitation, test performance, and competition. Medical students often start their training with a passion to care for and be of service to others. Their training will often acknowledge the importance of humanistic skills but time and energy is rarely within the medical school curriculum to become compassionate and empathic by becoming “what they repeatedly do.” In addition to the lack of attention and actual practice in this realm, a lack of self-care in exchange for test performance is encouraged within the culture. This further erodes compassion and empathy for others as poor self-care contributes to stress and burn-out. As faculty role models trained within this system, it is challenging to rediscover our own empathy and compassion, much less figure out how to change the training for the future. This degradation of compassion and empathy skills is well documented in academic medicine. While not entirely understood, contributing factors may include any or all of the following: focus on grades and evaluation, competition for residency, long hours, and decreased time and effort for self-care. Other potential culprits are poor faculty role models, medical technology, short office and hospital visits, and lack of long-term relationships with patients.

Erratum: Parathyroid hormone as a marker for metabolic bone disease of prematurity (Journal of Perinatology (2015) 35 (667)) doi:10.1038/jp.2015.64

Correction to: Journal of Perinatology (2014) 34, 787–791; doi:10.1038/jp.2014.97; published online 29 May 2014 Throughout the text, the units for concentrations of parathyroid hormone were incorrectly presented as mg dl−1. The correct unit is pg ml−1. The authors regret the error.

Parathyroid hormone levels in neonates with suspected osteopenia: Parathyroid hormone in neonates

The goal of this study is to describe secondary hyperparathyroidism in extremely low birthweight (ELBW) neonates and their response to enteral calcium carbonate (CaCO3) supplementation.