Mark Weems

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States

Introduction Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date. Methods We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use. Results Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7–12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5–5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2–6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%). Discussion Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Circulating hematopoietic and endothelial progenitor cells in newborn infants: Effects of gestational age, postnatal age and clinical stress in the first 3 weeks of life

INTRODUCTION Circulating endothelial progenitor cells (EPC) are bone marrow derived progenitors that can be mobilized by erythropoietin or in response to tissue injury, and participate in vascular repair. EPC are understudied in human neonates. Whether EPC frequency in newborn infants may be influenced by gestational age or postnatal stress is unknown. METHODS Blood samples were collected on day 1 of life and weekly for 3 weeks from hospitalized neonates for plasma erythropoietin and flow cytometry analysis for CD34+, CD34+CD45-, CD34+VEGFR2+ and CD34+CD45-VEGFR2+ cells (EPC). Associations between CD34+ cell subsets and clinical parameters were studied. RESULTS Forty five patients were enrolled. An inverse correlation with gestational age was observed for CD34+ and CD34+ VEGFR2+ cell frequencies in whole blood (WB) on day 1 (p<0.05). In preterm infants, CD34+ cell frequency decreased with increased postnatal age (p=0.0001) and CD34+VEGFR2+ cell frequency was higher at week 3 than on day 1 in WB (p=0.0002). On day one, CD34+ and CD34+CD45- cell frequencies in the mononuclear cell fraction (MNC) were higher in preterm than term infants (p=0.035 and p=0.049, respectively) but CD34+CD45-VEGFR2+ cell frequency (median 2.2/million MNC versus 3.8/million MNC) and erythropoietin levels were not significantly different. Transient increases in EPC were observed in five infants with infection. Four preterm infants who developed bronchopulmonary dysplasia had undetectable or low EPC through the first 3 weeks of life. CONCLUSIONS Gestational age and postnatal age influenced circulating CD34+ and CD34+VEGFR2+ but not CD34+CD45-VEGFR2+ (EPC) cell frequencies. Circulating EPC in neonates may be influenced by clinical stress.

Urinary Tract Infections in a Neonatal Intensive Care Unit

OBJECTIVE Our aim was to describe laboratory findings and imaging results for neonatal patients diagnosed with urinary tract infection (UTI). STUDY DESIGN Medical records were reviewed for infants diagnosed with UTI in a single neonatal intensive care unit (NICU) over a 13-year period. RESULTS Of the 8,241 patients admitted to the NICU during the study period, 137 infants were diagnosed with UTI. Imaging was reviewed for 101 patients. Renal pelvis dilation was found in 34% of patients and vesicoureteral reflux was found in 21%. Renal pelvis dilation was not associated with reflux (OR: 0.53 [95% CI: 0.18-1.5]). The sensitivity of urinalysis to detect a positive culture was 76%, and the specificity was 41%. Tests of cure for bacterial infections were uniformly negative. CONCLUSION Renal pelvis dilation was common but not associated with reflux among NICU patients diagnosed with UTI. Diagnostic criteria in this population are not well defined, and guidelines are needed for diagnosis and management of UTIs in NICU patients.

Electronic communication preferences among mothers in the neonatal intensive care unit

Objective:Mobile communication with the medical-care team has the potential to decrease stress among parents of infants admitted to the neonatal intensive care unit (NICU). We assessed mobile use and communication preferences in a population of urban minority NICU mothers.Study Design:A 30-question English language survey was administered to mothers of NICU patients.Results:The survey was completed by 217 mothers, 75% were Black, and 75% reported annual household income below

Plagiarism in Review

20 000. Only 56% had a computer with Internet access at home, but 79% used smartphones. Most (79%) have searched the Internet for health information in the past year. Receiving electronic messages about their babies was viewed favorably, and text messaging was the preferred platform. The majority of mothers felt electronic messaging would improve communication but should not replace verbal communication.Conclusion:Mobile communication is used widely in this population of NICU mothers and could potentially improve provider–parent communication and reduce parental stress.

The death knell of inhaled nitric oxide to prevent bronchopulmonary dysplasia

1. Mark Weems, MD 1. Associate Editor For more than 35 years, the editors of Pediatrics in Review (PIR) have turned to content experts to write review articles that can be used by pediatricians in daily practice. We also understand that our “Index of Suspicion” and “Visual Diagnosis” sections provide opportunities for young physicians to build their portfolios, and we welcome case submissions by junior faculty and residents when supervised by more experienced pediatricians. When I joined the Editorial Board 2 years ago as the first PIR editorial fellow, I was shocked by a disturbing trend in submitted articles: plagiarism. Plagiarism is not unique to PIR. In fact, it is so prevalent in medical literature that Miguel Roig’s 2013 PubMed search for “plagiarism” resulted in 1,086 articles. (1) As of August 24, 2016, that number has risen to 1,461. Plagiarism threatens the authority of our peer-reviewed journal and puts our publisher, the American Academy of Pediatrics (AAP), at risk for copyright infringement. In an effort to prevent plagiarized material from being published, all manuscripts submitted to PIR are screened with Crossref Similarity Check, powered by iThenticate (Crossref, Lynnfield, MA, and Turnitin, LLC, Oakland, CA) and compared against a database containing more than 60 billion documents. This process is described in our author instructions, but we continue to receive plagiarized manuscripts. Therefore, we feel it is important to share some deeper insight into the issue of plagiarism. Reading through a small selection of the 1,461 …

Survey of ECMO practices for infants with hypoxic ischemic encephalopathy

⚬ Inclusion criteria: (1) Gestational age <30 weeks, (2) Birthweight <1250 g, (3) postnatal age 5–14 days, (4) requiring positive pressure ventilation (defined as mechanical ventilation; and including CPAP for infants <800 g). ⚬ Exclusion criteria: (1) life-threatening anomaly, (2) congenital diaphragmatic hernia, (3) bilateral grade IV intraventricular hemorrhage, (4) right-to-left shunt dependent lesion, (5) prior exposure to iNO, (6) use of an additional investigatory agent.

Hemodynamically significant patent ductus arteriosus and the development of bronchopulmonary dysplasia

ObjectiveHistorically, some physicians are reluctant to offer extracorporeal membrane oxygenation (ECMO) to infants with neonatal encephalopathy. This study describes how ECMO practices have changed since the development of therapeutic hypothermia (TH) for neonatal encephalopathy.Study designA 22-question electronic survey was sent to neonatal medical directors and ECMO directors in the USA and Canada. Participants were queried on TH and ECMO practices and if they would offer ECMO given certain clinical factors; confidential responses were compared with a similar survey conducted in 2008.ResultA total of 356 physicians were invited to participate, and the response rate was 25%. Seventy-two percent had initiated or referred for ECMO during cooling therapy. Compared with the 2008 survey, participants were more likely to offer ECMO for moderate and severe encephalopathy. Ninety-four percent offer hypothermia for neonatal encephalopathy, but only 24% have written ECMO criteria for such patients. Neonatologists were more likely than non-neonatologists to offer ECMO for mild and moderate encephalopathy.ConclusionECMO use with neonatal encephalopathy has increased since TH has become standard care. Wide variability in practice remains with important differences between neonatologists and non-neonatologists.

Shaken or Stirred? Evaluating the combination of budesonide–surfactant for survival free of bronchopulmonary dysplasia

Patent ductus arteriosus (PDA) is prevalent in premature newborns and has been linked to the development of bronchopulmonary dysplasia (BPD), a serious pulmonary complication of premature birth. Although a causal relationship has not been proven, the link is greatest among infants born at lower gestational age who are treated with mechanical ventilation in the presence of a large ductal shunt. Despite strong association in epidemiological studies, treatment of a patent ductus arteriosus has not been shown to prevent BPD, and some therapies may increase the risk of BPD. We describe preclinical and clinical data demonstrating the association of a PDA with BPD, highlight the effects of surgical and pharmacological treatment, and explore the implications of recent clinical trials for the management of PDA in the premature newborn.

Congenital Diaphragmatic Hernia: Maximizing Survival

The magic bullet that prevents bronchopulmonary dysplasia (BPD) in very low-birthweight infants without increasing long-term side effects remains elusive. Because pulmonary inflammation is likely critical to the pathogenesis of BPD, numerous investigatorshaveattempted toprevent the development of BPD with a wide variety of postnatal corticosteroid regimens (1). Unfortunately, systemic corticosteroids have been linked to increase risk of adverse neurodevelopmental outcomes (2). Inhaled corticosteroids combine more direct action on lung tissue with less systemic effect, but inhaled corticosteroids have also failed to reduce BPD (3,4). Adding budesonide to surfactant potentiates thedeliveryof corticosteroid to theperipheral lung tissue (5). The authors posit that delivering this combination therapy early in the course of illness may unlock the minimum required anti-inflammatorystimulinecessary topreventBPDwhileavoiding adverseoutcomes.Apaucityofdatamakesassessing the impact of the specific surfactant preparationused in this study difficult. This would likely be worthwhile to explore in future research. Yeh et al. found a significant reduction in the incidence of BPD or death after administration of budesonide–surfactant as compared to surfactant alone. The effect can be attributed to a reduction in BPD alone without a significant effect onmortality. Whilenotpowered toexamineneurodevelopmental outcomes, it isencouragingthat thesurvivinginfants exhibited no trend towards adverse outcome at two to three years old. Both findings were confirmed by meta-analysis (6) with the group’s prior pilot study (7). The major limitation of this study is the high incidence of BPD in the control group (50%). In a population with a lower prevalence of BPD, the relative risk reduction and number needed to treat are likely to be many fold different. Many infants experienced significant intervention prior to randomisation that could alter themagnitudeof the treatment effect and thus the number needed to treat, such as mechanical ventilation and oxygen administration. While randomisation prevents the introduction of significant bias in this study, earlier surfactant administration may potentiate the budesonide effect when compared to other strategies shown to reduce BPD (8). The role of budesonide– surfactant administration should be re-evaluated in conjunction with other current treatment strategies known to prevent BPD. This would reassure clinicians that budesonide–surfactant therapy continues to offer benefit in the context of current clinical practice. In the end, Yeh et al. represent a potentially powerful intervention to reduce the risk of BPD. Considering the less than satisfactory results achieved by previous corticosteroid delivery methods, this is a significant achievement. However, the previous failure of postnatal corticosteroid administration has created a paradox, that is difficult to overcome. Clinicians continue to use corticosteroids in infants with moderate-to-severe BPD despite known risks, while at the same time demanding a high bar of evidence be achieved before altering current management. Before budesonide–surfactant can become the standard of care, further large trials are required in populations with a lower prevalence of BPD. We advocate for a multicentre trial in conjunction with noninvasive respiratory management that is powered to evaluate neurodevelopmental outcomes.