Shilpi Chabra

Rising prevalence of gastroschisis in Washington State.

The aim of this study was to assess gastroschisis prevalence in Washington (WA) State in relation to putative risk factors. Gastroschisis prevalence was calculated from the WA State birth cohort during 1987–2006 using an administrative database with birth certificate data linked with hospital discharge records and the ICD-9 procedure code 54.71, which specifies gastroschisis repair. Poisson regression analysis was used to evaluate time trends while adjusting for risk factors. Birth year was included as a linear term. Maternal age, smoking, race, residence in urban versus rural area, geographic region (eastern versus western Washington), paternal age, and infant gender were included as categorical factors. Prevalence ratios were adjusted for birth year and all of the preceding factors. Two hundred and eighty-two infants with gastroschisis were identified. In the adjusted analysis, the prevalence ratio for gastroschisis was 1.1 per year (95% CI 1.08–1.13), indicating an average 10% increase per birth year. Teen mothers were at a higher risk compared to mothers ≥25 yr old (adjusted rate ratio [aRR] 8.02; 95% CI 5.30–12.13), as were teen fathers (aRR 2.35; 95% CI 1.48–3.74) compared to fathers ≥25 years old. Maternal smoking was associated with a higher risk compared to those who were nonsmokers (aRR 1.58; 95% CI 1.19–2.09). Black mothers had a lower risk compared with white mothers. There was no association with geographic classification of mothers residence. Gastroschisis prevalence has increased in WA, particularly in teen mothers and in smokers. This is not explained by a rise in teenage pregnancies or maternal smoking. Further investigation of factors specific to teenage lifestyle is warranted.

A fatal neonatal case of medium-chain acyl-coenzyme a dehydrogenase deficiency with homozygous A→G985 transition

A term neonate became lethargic and hypotonic at 46 hours of age and died 10 hours later despite supportive therapy. Urinary organic acids indicated medium-chain acyl-coenzyme A dehydrogenase deficiency, and DNA studies confirmed this disorder. Neonatal symptoms in this enzyme deficiency have rarely been reported, and recent reviews have ignored or discounted this presentation.

Vitamin A Status After Prophylactic Intramuscular Vitamin A Supplementation in Extremely Low Birth Weight Infants

BACKGROUND Vitamin A supplementation (VAS) is recommended to prevent bronchopulmonary dysplasia (BPD). Our objective was to evaluate the effect of VAS on vitamin A (VA) status. We hypothesized that VAS would improve VA status in extremely low birth weight (ELBW) infants. MATERIALS AND METHODS Retrospective chart review of infants 1 year before and after initiation of VAS (5000 IU 3 times a week intramuscularly [IM]; total 12 doses). Linear regression was used to model impact of VAS on VA status (retinol level and retinol/retinol binding protein [RBP] ratio). Models were adjusted for time and generalized estimating equations were used to account for intraindividual correlation. RESULTS Sixty-seven infants (mean gestational age 26 ± 2 weeks; mean body weight 803 ± 142 g) were included; 35 received VAS and 32 did not (no-VAS). Both groups had similar baseline characteristics. Infants who received VAS had mean retinol levels that were 9.0 mcg/dL (95% confidence interval [CI], 4.9-13.2; P < .001) higher and mean retinol/RBP ratios that were 0.21 (95% CI, 0.07-0.36; P = .005) higher than the no-VAS group. Retinol and retinol/RBP ratio increased with time (P < .001). Fewer infants in the VAS group had VA deficiency (retinol/RBP ratios <0.7) compared with the no-VAS group. Culture-positive sepsis was more common in the VAS group (48% vs 12%; P = .002). CONCLUSIONS VA status in ELBW infants was improved and maintained over the first month of life with IM VAS. Because of concerns for potential risks of repeated injections, further studies are indicated to evaluate the optimal mode of VA delivery in preterm infants.

Clearing the Confusion About Completed Weeks of Gestation

It is important that all providers, including physicians and nurses, have a standard definition for completed weeks of gestation. The definition of the late preterm infant (LPT) varies despite being established in 2005 when the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) recommended that births between 34 completed weeks (34 0/7 weeks or day 239) and fewer than 37 completed weeks (36 6/7 weeks or day 259) gestation be referred to as late preterm (Raju, 2006). However, LPT infants are sometimes defined as infants born between 34 and 36 completed weeks gestation. The definition of completed weeks gestation needs clarification in that 36 weeks gestation is completed at 36 0/7 and not at 36 6/7. The 36th week of gestation is completed when the last day of week 36 (which ranges from 35 0/7– 35 6/7) is completed. In other words, week 36 of gestation begins on the first day 35 0/7 and ends on the last day 35 6/7. Week number 37 begins on the next day 36 0/7 and is completed on the last day of the 37th week, 36 6/7. Using the definition as infants born between 34 and 36 completed weeks for LPT infants is erroneous as it excludes the infants born between 36 0/7 and 36 6/7 weeks.

Re: Advanced maternal age increases the risk of very preterm birth, irrespective of parity: a population‐based register study

Sir, Marasinghe and Khot comment on the recent publication in BJOG regarding the clinical management of vaginal seeding, for which I wrote the accompanying mini commentary. The practice of vaginal seeding (VS) needs perspective, not more hyperbole. Although some providers may feel pressure from mothers to voice acceptance, we need to be aware of what VS is unlikely to accomplish, as well as the potential dangers from both unwanted flora and from the distraction away from other necessary newborn measures immediately after birth. Any new practice potentially distracts from other more critical tasks. Vaginal seeding (VS) appears to temporarily change neonatal gastrointestinal (GI) flora but not skin flora, and there are scientifically plausible reasons that GI flora may influence immune pathways. How much change in the neonatal immune pathway takes place from transient exposure to maternal vaginal flora is open to question; however, autism is dependent on multiple complex genetic issues, and school performance depends upon a myriad of complex interactions. As the mode of delivery does not influence academic performance, it is nothing but hyperbole to suggest that academic performance would be changed by VS.& References

Resident Burnout: Urgent Need for Peer-Appointed “Wellbeing Officers” to Strengthen Resilience

To the Editor: I read the interesting study wherein Holmes and colleagues measured contributors to resident burnout and also interventions to mitigate its risk [1]. This study is unique because it evaluates the perspectives of both residents and program directors (PDs) and studies all specialties at a tertiary academic hospital; additionally, residents also identified barriers to treatment. This valuable paper raises two important issues. First, 25% of residents believed (incorrectly) that burnout is a reportable condition to the medical board. This is a critical finding in that acknowledgement of burnout is considered to be an admission of distress and stigma by residents, thereby highlighting the important need for education and improving awareness. It is imperative to provide information to residents regarding interventions that address work-life balance and eliminate such false perceptions that are likely to reduce help-seeking behavior. Chaukos and colleagues found that residents who experience burnout have lower levels of mindfulness and coping skills and recommend that residency training programs should initiate curricula combining mindfulness and self-awareness coping strategies with cognitive behavioral strategies to offset burnout symptoms [2]. Second, both groups (residents and PDs) reported “feeling unappreciated” to be a major burnout contributor; however, PDs underestimated rates of resident burnout. The authors identify this perception of underappreciation to be a potential intervention point for health-care systems and recommend addressing problems of insufficient call rooms/workspace and increasing administrative assistance. They also advocate using academic psychiatrists to support struggling residents; however, it is important to respectfully emphasize that, although helpful, this may not be received well due to residents’ perceived stigma of a psychiatric issue. Resilience, defined as the ability of an individual to maintain personal and social stability despite adversity, is fostered by resident engagement with friends, family, mentors, and more importantly, with peers. Peer groups with shared training experiences can decrease isolation and enable residents to learn coping skills that are crucial in building resilience. One of the main initiatives of graduate medical education (GME) departments should be to raise awareness of burnout and help equip residents with the tools necessary to educate themselves about strategies that cultivate resilience. There is emerging evidence that peer-support programs are more impactful compared to faculty-led support, as reported by Houpy and colleagues, wherein medical students most often discussed difficult clinical events with their peers (90%), while 60% discussed with residents and only 37% discussed with the attending, which highlights the dynamics of team hierarchy [3]. I am calling for every GME program’s mission to include strengthening resilience of resident physicians and standardizing efforts to ameliorate burnout. This is a huge undertaking, which could be expensive and daunting for the GME office. One solution could be through formal “resiliency” training offered by the GME department, perhaps with the help of chief residents to ensure implementation throughout the residency training program. This could potentially be facilitated by peer-appointed chief wellbeing officers (CWO)—a group of individuals who are skilled in strategies to build resilience and who serve as resident ambassadors to help establish a “just culture” that balances accountability with a no-blame policy. CWOs, appointed through the GME office, could lead the various levels of resident trainees through the basics of * Shilpi Chabra schabra@u.washington.edu

International Classification of Diseases, 10th Revision, coding for prematurity: need for standardized nomenclature.

The International Classification of Diseases, Ninth Revision, Clinical Modification was introduced in the United States in 1979 as a coding system to document inpatient diagnostic and procedural codes. However, transition to International Classification of Diseases, 10th Revision (ICD-10) has been federally mandated by October 2015 due to advances in medical technology and procedures in medicine. This includes ICD-10, Clinical Modification and ICD-10, Procedure Coding System. The ICD-10 coding set is more detailed and specific and will add 54 000 diagnosis codes and 83 000 procedure codes to the International Classification of Diseases, Ninth Revision, Clinical Modification code set, thereby accounting for increased granularity of codes needed for evidence-based medicine. This article describes the importance of need for specificity of the codes and emphasizes the role of training in preparing for implementation of the ICD-10 coding system. An example is made for the need for accuracy in ICD-10 codes for prematurity as regards defining the premature population using standardized nomenclature.

Postterm, postdates, and prolonged pregnancy: need for simplification of terminology.

To the Editor: I read with great interest the article by Schmitz et al, wherein the authors use the term “prolonged pregnancy” for pregnancies beyond 41 weeks of gestation. In another recent article, the term “postdate” was used for labor induction at 41 weeks of gestation. Use of the two terms interchangeably, and often with postterm pregnancy, is confusing and needs clarification. Another confusing fact is a variable definition of prolonged pregnancy, which has been defined as 42 completed weeks of gestation or more, pregnancy at or beyond 40 3/7 weeks, and as pregnancy at or beyond 41 weeks or 287 days after the last menstrual period. Although a 2004 Practice Bulletin from the American College of Obstetricians and Gynecologists (the College) recommends avoiding the use of the term “postdates” owing to it’s being poorly defined, this term continues to be used as a common reason for induction of labor for pregnancy that continues after 41 completed weeks of gestation. Pregnant women who have passed their estimated date of delivery but who have not yet reached 42 weeks of gestation (those between 40 and 42 completed weeks of gestation) remain an important group for whom there is ongoing research regarding antenatal fetal surveillance and indications for induction of labor. In 2013, the College Committee Opinion on definition of term pregnancy established that the period of gestation from 39 0/7 weeks through 40 6/7 weeks is full-term, and late-term is defined to range from 41 0/7 weeks through 41 6/7 weeks. Postterm pregnancy is defined by the College as a pregnancy that has reached or extended beyond 42 0/7 weeks of gestation or 294 days from the last menstrual period, and its incidence in the United States has been reported to be 5.5% in 2011. Additionally, to add to the confusion, the International Classification of Diseases, 10th Revision (ICD-10) codes for prolonged and postterm pregnancy are imprecise. It defines prolonged pregnancy as pregnancy greater than 42 weeks of gestation, which is coded with ICD-10 code O48.1 (Box 1). Postterm pregnancy is pregnancy greater than 40 completed weeks to 42 completed weeks and is coded with ICD-10 code O48.0. This is inaccurate, because pregnancy from 40 0/7–40 6/7 weeks is defined as full-term and a late-term pregnancy is defined as one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation.

Effective surveillance of gastroschisis and omphalocele: separate International Classification of Diseases, Ninth Revision codes!

To the Editor: Many birth defects surveillance programs use the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system for identification of cases and data collection. It is critical to effectively code birth defects for accurate surveillance, monitoring, and prevention strategies. A major challenge in interpreting data on gastroschisis and omphalocele results from inaccurate coding. Until just recently, both gastroschisis and omphalocele have been coded by a common ICD-9 code 756.79, even though they are completely different abdominal wall defects [1]. However, in the 2010 version of the Ingenix ICD-9-CM expert for physicians [2], both gastroschisis and omphalocele have separate specific ICD-9 codes (Fig. 1): 756.72 for omphalocele and 756.73 for gastroschisis. It is also important to note that the 2 ICD-9 codes, 756.79 and 756.7, that were previously used to identify cases of gastroschisis [3,4] now exclude both gastroschisis and omphalocele and represent “Other congenital anomalies of the abdominal wall” and “Anomalies of the abdominal wall,” respectively. These 2 older ICD-9 codes, therefore, should henceforth not be used for identification of cases of gastroschisis because of the potential for error in interpretation. Rising prevalence of gastroschisis, especially in adolescent mothers, has been of recent concern globally because of several reports published worldwide [5]. The cause of this phenomenon has been elusive, and research evaluating it is in need of resources [6]; however, the barrier of effective coding for this defect, at least, has been crossed. Further studies, including public health evaluation, are needed to help identify the potential risk factors associating gastroschisis and low maternal age.

Limited Ultrasound Protocol for Upper Extremity Peripherally Inserted Central Catheter Monitoring: A Pilot Study in the Neonatal Intensive Care Unit

To assess whether a limited ultrasound (US) scanning protocol to monitor the upper extremity peripherally inserted central catheter (PICC) location in neonates is feasible for experienced US operators.