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Point-of-care ultrasound (POCUS) has increasingly been used by neonatal providers in neonatal intensive care units in the United States. However, there is a lack of literature addressing the complexities of POCUS coding and billing practices in the United States. This article describes the coding terminology and billing process especially those relevant to neonatal POCUS. We elucidate considerations for neonatal POCUS billing framework and workflow integration. Directions on image storage and supporting documentation to facilitate efficient reimbursement, compliance with billing regulations, and appeal to insurance claim denial are discussed. Key Points Code neonatal POCUS procedure precisely allows accurate reimbursement and reduced errors in billing. Document details to support medical necessity and reimbursement claims effectively. Adhere to regulations to avoid audits, denials, and ensure proper reimbursement. [ABSTRACT FROM AUTHOR]

Objective Administering surfactant timely and appropriately is important to minimize lung injury but remains challenging in preterm neonates with respiratory distress syndrome. The published literature supports that lung ultrasound (LUS) score can predict surfactant need. Neonatal LUS scanning specification and parameter setting guidelines have been recently published for standardization. However, variations in scanning protocols and machine settings hinder its clinical implementation widely. This observational study aims to internally validate the suggested LUS protocol in a neonatal intensive care unit to establish a correlation between LUS scores and surfactant need as the first step of integrating LUS in the clinical practice. Study Design LUS was performed on 40 eligible preterm neonates within 3 hours after birth or before surfactant administration between May 2020 and March 2021. The neonates were between 27 and 32 weeks' gestational age, and all had respiratory distress. Neonates with known congenital anomalies were excluded. A high-frequency linear probe was used to obtain LUS images from six lung zones which were scored using a 0 to 3 system, yielding a maximum of 18 points. Treating physicians were blinded to the LUS score. Receiver operating characteristic analysis determined the optimal LUS score cut-off for predicting surfactant need. Results Fifteen of the 40 neonates (38%) required higher oxygen fraction and received surfactant. In our cohort, an LUS score ≥10 was identified as the optimal cut-off for predicting surfactant need, with a sensitivity of 80% and specificity of 84%. The area under the curve was 0.8 (p = 0.0003). LUS predicted surfactant need at a median of 3.5 hours earlier than traditional clinical decision (p < 0.0037). Conclusion LUS is a helpful adjunct for predicting surfactant need in preterm neonates. This study describes an approach to implement the LUS protocol and score for clinical decision-making in the clinical practice. Key Points LUS is a helpful adjunct for predicting surfactant need in preterm neonates. Machine setting variation and probe selection may affect LUS image and score. LUS score should be validated at the local unit before clinical implementation. [ABSTRACT FROM AUTHOR]

Point-of-care ultrasound (POCUS) holds immense potential to manage critically deteriorating infants within the neonatal intensive care unit (NICU) and is increasingly used in neonatal clinical practice worldwide. Recent ultrasound-based protocols such as the Sonographic Assessment of liFe-threatening Emergencies-Revised (SAFE-R) and Crashing Neonate Protocol (CNP) offer step-by-step guidance for diagnosing and addressing reversible causes of cardiorespiratory collapse. Traditionally, pulseless electrical activity (PEA) has been diagnosed solely based on absent pulses on clinical examination, disregarding myocardial activity. However, integrating POCUS into resuscitation unveils the concept of pseudo-PEA, where cardiac motion activity is observed visually on the ultrasound but fails to generate a detectable pulse due to inadequate cardiac output. Paradoxically, existing neonatal resuscitation protocols lack directives for identifying and effectively leveraging pseudo-PEA insights in infants, limiting their potential to enhance outcomes. Pseudo-PEA is extensively described in adult literature owing to routine POCUS use in resuscitation. This review article comprehensively evaluates the adult pseudo-PEA literature to glean insights adaptable to neonatal care. Additionally, we propose a simple strategy to integrate POCUS during neonatal resuscitation, especially in infants who do not respond to routine measures. Conclusion: Pseudo-PDA is a newly recognized diagnosis in infants with the use of POCUS during resuscitation. This article highlights the importance of cross-disciplinary learning in tackling emerging challenges within neonatal medicine. What is known: • Point-of-Care ultrasound (POCUS) benefits adult cardiac arrest management, particularly in distinguishing true Pulseless Electrical Activity (PEA) from pseudo-PEA. • Pseudo-PEA is when myocardial motion can be seen on ultrasound but fails to generate palpable pulses or sustain circulation despite evident cardiac electrical activity. What is new: • Discuss recognition and management of pseudo-PEA in infants. • A proposed algorithm to integrate POCUS into active neonatal cardiopulmonary resuscitation (CPR) procedures. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to establish neonatal serum triglyceride (TG) level reference ranges during lipid infusion and correlate peak TG with neonatal outcomes. Study Design  This is a retrospective review of 356 neonates with 696 TG measures obtained in four neonatal intensive care units between 2015 and 2017. TG was evaluated collectively to establish a reference range and a threshold limit. To analyze the effects of a higher TG threshold, neonates were categorized by their peak TG: <180 (TG <180), 180 to 400 (TG 180–400), and > 400 mg/dL (TG >400). Univariable and multivariable regression models were constructed to compare peak TG to patient characteristic and clinical outcomes. Results  The frequency of TG > 400 mg/dL was 5% and found only in neonates weighing < 1.5 kg. Neonates in the TG 180–400 (n  = 91) group were significantly lower in birth weight and gestational age, had lower 5-minute APGAR scores, and had increased ventilatory requirement when compared with neonates in the TG <180 (n  = 240) group (all p  < 0.001). The TG 180–400 group had increased risk of severe intraventricular hemorrhage (p  = 0.02) and bronchopulmonary dysplasia (p  = 0.03). Elevated TG was associated with mortality (odds ratio [OR]: 14.4, p  < 0.001) in univariable analysis, but the relationship weakened (OR: 4.4, p  = 0.05) after adjusting for comorbidities in multivariable logistic regression. Conclusion  It is unclear if the adverse outcomes seen in neonates with higher peak TG were due to elevated TG alone, or whether illness severity predicted the increased TG. More prospective studies are needed to further delineate the relationships. [ABSTRACT FROM AUTHOR]

Metaplastic breast cancer is a rare aggressive subtype of breast cancer for which there are no clear treatment guidelines regarding the optimal surgical approach. This systematic review and meta‐analysis aimed to evaluate survival outcomes of patients with metaplastic breast cancer undergoing breast conservation compared with mastectomy. We identified studies from MEDLINE, Pubmed, EMBASE, Google Scholar, the Cochrane Library Register of Controlled Trials and the EBM Reviews Register. Studies were deemed suitable for inclusion where they compared breast‐conserving surgery to mastectomy with the primary outcome of overall survival. Survival data were pooled using a random‐effects model.From the 456 citations screened by our search, three studies were assessed as eligible for inclusion. There were a total of 2995 patients who underwent mastectomy and 1909 who underwent breast conservation. The median follow‐up time was 43 months. Meta‐analysis demonstrated no significant difference between breast conservation and mastectomy (pooled HR 0.89, 95% CI, 0.56–1.42, p = 0.631). Wide local excision, in conjunction with adjuvant radiation and judicious use of chemotherapy, may be a reasonable alternative to mastectomy as surgical management of metaplastic breast cancer as part of an individualized, multidisciplinary approach. [ABSTRACT FROM AUTHOR]

• About one third of pregnant women with asymptomatic or mildly symptomatic SARS-CoV-2 positive had comorbid depression, anxiety or substance use and about 13% were prescribed antidepressant medications during pregnancy. • Significantly more patients with (compared to without) psychiatric comorbidity had cesarean delivery (36.6% vs. 24.9%). • No effect of psychiatric comorbidity on the incidence of preterm birth. • No effect of psychiatric comorbidity and maternal infection timing on birth weight or neonatal head circumference. The effect of psychiatric comorbidity on pregnancy outcome among SARS-CoV-2 positive women with asymptomatic and mildly symptomatic infections remains largely unknown. We reviewed the electronic medical records of all pregnant women who received care at Mayo Health System and tested positive for SARS-CoV-2 (RT-PCR) from March 2020 through October 2021. Among 789 patients, 34.2% (n = 270) had psychiatric comorbidity. Of those with psychiatric comrobidity, 62.2% (n = 168) had depression prior to pregnancy, and 5.2% (n = 14) reported new-onset depression during pregnancy. Before pregnancy, 65.6% (n = 177) had anxiety, and 4.4% (n = 12) developed anxiety during pregnancy Thirteen percent of SARS-CoV-2 positive pregnant women (n = 108) received psychotropic medication during pregnancy. In addition, 6.7% (n = 18) and 10.7% (n = 29) of pregnant women with psychiatric comorbidity had documented nicotine, cannabis and/ or illicit substance use during and prior to pregnancy, respectively. We depicted a significantly higher risk for cesarean delivery [35.6% vs. 24.9%) in asymptomatic and mildly symptomatic SARS-CoV-2 positive pregnant women with psychiatric comorbidity. In conclusion, the prevalence rates of depression, anxiety, and prescribed antidepressant medications during pregnancy among asymptomatic and mildly symptomatic SARS-CoV-2 infected women were substantially higher than average, which negatively impacted pregnancy and neonatal outcomes. [ABSTRACT FROM AUTHOR]

: The molecular signals that control decisions regarding progenitor/stem cell proliferation versus differentiation are not fully understood. Differentiation of motile cilia from progenitor/stem cells may offer a simple tractable model to investigate this process. Wnt and Notch represent two key signaling pathways in progenitor/stem cell behavior in a number of tissues. Adenomatous Polyposis Coli, Apc is a negative regulator of the Wnt pathway and a well known multifunctional protein. Using the cre-LoxP system we inactivated the Apc locus via Foxj1-cre, which is expressed in cells committed to ciliated cell lineage. We then characterized the consequent phenotype in two select tissues that bear motile cilia, the lung and the testis. In the lung, Apc deletion induced β-catenin accumulation and Jag1 expression in ciliated cells and by lateral induction, triggered Notch signaling in adjacent Clara cells. In the bronchiolar epithelium, absence of Apc blocked the differentiation of a subpopulation of cells committed to the ciliogenesis program. In the human pulmonary adenocarcinoma cells, Apc over-expression inhibited Jag1 expression and promoted motile ciliogenic gene expression program including Foxj1, revealing the potential mechanism. In the testis, Apc inactivation induced β-catenin accumulation in the spermatogonia, but silenced Notch signaling and depleted spermatogonial stem cells, associated with reduced proliferation, resulting in male infertility. In sum, the present comparative analysis reveals the tissue-dependent consequences of Apc inactivation on proliferation and differentiation of ciliated cell progenitors by coordinating Wnt and Notch signaling. [ABSTRACT FROM AUTHOR]

Small numbers of hiatus hernias are very large, cause other nonreflux symptoms as well, and have an attached morbidity and mortality through strangulation. Patients are elderly and unfit, and surgery has been troubled by recurrence. Mesh repair has been advocated in an attempt to reduce a perceived high revision rate. We describe the early results of a 'composite' form of laparoscopic repair where no mesh has been used, with excellent early results in levels of symptom control, morbidity, mortality, and recurrence, and discuss the value of mesh repair as a primary operation against the recently recognized severe complications secondary to mesh repair failure. The technique requires five-port laparoscopy, primary nonabsorbable diaphragmatic repair, and fixation of the cardioesophageal junction, within a fundoplication, to the posterior crural repair and median arcuate ligament. Thirty-eight patients with a mean age of 70 years operated on during 1 year had a recurrence of 6% but of minimal size by objective measure between 4 and 19 months of operation. Mesh repair in the literature is poorly supported, highly complicated, and by these figures not required. [ABSTRACT FROM AUTHOR]

Abstract: Adenosine deaminase (ADA)-deficient Severe Combined Immunodeficiency (ADA-deficient SCID) is characterized by impaired lymphocyte development and function resulting from the adenosine metabolism defect. Enzyme replacement therapy with polyethylene glycol-conjugated adenosine deaminase (PEG-ADA) minimizes infectious complications of ADA-deficient patients who have not received bone marrow transplantation. In PEG-ADA therapy, enzymatically active ADA continuously circulates to act as a metabolic sink, detoxifying the adenosine and deoxyadenosine metabolites that accumulate to high levels in the absence of ADA. Studies have shown that upon the initiation of PEG-ADA therapy, the absolute numbers of circulating T and B lymphocytes and NK cells increase and protective immune function develops. However, the long-term efficacy is unknown. This retrospective study was designed to assess the long-term effectiveness of PEG-ADA treatment, based on evaluation of the immune function of nine ADA-deficient SCID patients (age 5–15) treated over the past decade. The results showed that the lymphocyte counts of all of the PEG-ADA treated patients were below the normal range at all times, despite initial improvements. A gradual decline of mitogenic proliferative responses occurred after a few years of treatment and normal antigenic response occurred less than expected. To this date, these low numbers and functions of lymphocytes had been adequate to provide protective immunity. These patients should be followed closely to detect a premature decline in immune function with aging in future decades of PEG-ADA therapy. [Copyright &y& Elsevier]

A Phyllodes Tumour (PT) is an uncommon fibroepithelial lesion, with three histological grades - benign, borderline and malignant. PTs cause significant challenges in diagnosis, management and prognostication. Recent publications have clarified the definitions and prognostication of PTs. Contemporary data currently challenge international guidelines on PT management. We performed an in-depth literature review to develop a best-practice management algorithm for PTs. Diagnostic recommendations are that neither current imaging techniques, nor fine-needle biopsies, can reliably diagnose a PT. Core needle biopsy is the optimal diagnostic technique. Indeterminate or suspicious lesions are recommended to undergo an excisional biopsy due to the inherently heterogeneous nature of PTs. Management guidelines are that benign PTs should be completely excised, although an involved margin is acceptable in select situations. Borderline PTs should have a clear margin on excision due to their higher risk of recurrence, as well as the potential for a recurrence to progress to a malignant PT. In malignant PTs, a margin of 3 mm is acceptable as there is no reduction in recurrence risk if margins are >3 mm. Routine axillary surgery is not indicated in PTs, with axillary surgery only indicated in a histologically-confirmed positive axilla. Adjuvant treatment recommendations are that borderline and malignant PTs should be discussed at MDT, with radiotherapy considered in both. Chemotherapy should be discussed in malignant PT patients. In summary, we have developed an up-to-date simple algorithm to guide the surgeon's management of patients diagnosed with PTs and reduce excessive surgery. [ABSTRACT FROM AUTHOR]

Background: Wire‐guided localization has been the mainstay of localization techniques for non‐palpable breast and axillary lesions prior to excision. Evidence is still growing for relatively newer localization technologies. This study evaluated the efficacy of the wireless localization technology, SCOUT®, for both breast and axillary surgery. Methods: Data were extracted from a prospective database (2021–2023) of consecutive patients undergoing wide local excision, excisional biopsy, targeted axillary dissection, or axillary lymph node dissection with SCOUT at a high‐volume tertiary centre. Rates of successful reflector placement, intraoperative lesion localization, and reflector retrieval were evaluated. A survey of surgeon‐reported ease of lesion localization and reflector retrieval was also evaluated. Clinical trial registration: ACTRN386751. Results: One‐hundred‐ninety‐five reflectors were deployed in 172 patients. Median interval between deployment and surgery was 3 days (range 1–20) and mean distance from reflector to lesion was 3.2 mm (standard deviation, SD 3.1). Rate of successful localization and reflector retrieval was 100% for both breast and axillary procedures. Mean operating time was 65.8 min (SD 33). None of the reflectors migrated. No reflector deployment or localization‐related complications occurred. Ninety‐eight percent of surgeons were satisfied with ease of localization for the first half of cases. Conclusion: SCOUT is an accurate and reliable method to localize and excise both breast and axillary lesions, and it may overcome some of the limitations of wire‐guided localization. [ABSTRACT FROM AUTHOR]

Background: Superparamagnetic iron oxide (SPIO) (Magtrace®) is a non‐radioactive liquid tracer that can stay in the sentinel lymph nodes for 30 days. Injection of SPIO at time of primary breast surgery where upfront sentinel lymph node biopsy (SLNB) is not immediately indicated allows for a return to theatre if pathology then identifies invasive disease. SLNB is associated with paraesthesia, pain, seroma formation and lymphoedema risk. Hence, our study aims to assess the use of SPIO to avoid upfront SLNB in breast surgery for ductal carcinoma in situ (DCIS) and prophylaxis. Methods: Retrospective single‐centre study of consecutive patients who underwent injection of SPIO tracer at time of primary breast surgery to avoid upfront SLNB at Chris O'Brien Lifehouse, Sydney, NSW, Australia over a 10‐month period. Results: SPIO was injected 38 times, with 34 at time of mastectomy and four cases at time of wide local excision. The indication for surgery was DCIS in 18 cases, risk reduction in 17 cases and other indications in three patients. Six cases (15.8%) required delayed SLNB (D‐SLNB) due to the finding of invasive disease on post‐operative histopathology. All patients who underwent D‐SLNB had nodes successfully localized with SPIO. Conclusion: In our cohort, 84.2% of cases were able to avoid upfront SLNB, and hence avoid the associated complications of SLNB. SPIO injection was successful in localizing the SLN in all cases at time of surgery for D‐SLNB. This technique was safe with few associated complications. [ABSTRACT FROM AUTHOR]

Objective Spontaneous intestinal perforation (SIP) occurs commonly in extremely low gestational age newborns (ELGANs; <30 weeks' GA). Early, concurrent neonatal use of indomethacin (Neo_IN) and hydrocortisone (Neo_HC) is a known risk for SIP. Mothers in premature labor often receive indomethacin (Mat_IN) for tocolysis and steroids (Mat_S) for fetal maturation. Coincidentally, ELGANs may receive Neo_IN or Neo_HC within the first week of life. There are limited data on the effect of combined exposures to maternal and neonatal medications. We hypothesized that proximity exposure to these medications may increase the risk of SIP. Study Design We reviewed the medical records of ELGANs from June 2014 to December 2019 at a single level III neonatal intensive care unit. We compared antenatal and postnatal indomethacin and steroid use between neonates with and without SIP. For analysis, chi-square, Student's t -test, Fisher's exact test, and Mann–Whitney U tests were used. Results Among 417 ELGANs, SIP was diagnosed in 23, predominantly in neonates < 26 weeks' GA (n = 21/126, 16.7%). Risk factors analysis focused on this GA cohort in which SIP was most prevalent. Mat_IN administration within 2 days of delivery increased SIP risk (odds ratio: 3; 95% confidence interval: 1.25–7.94; p = 0.036). Neo_HC was not independently associated with SIP (p = 0.38). A higher proportion of SIP group had close temporal exposure of Mat_IN and Neo_HC compared with the non-SIP group, though not statistically significant (14 vs. 7%, p = 0.24). Conclusion Peripartum Mat_IN was associated with increased risk for SIP in this small study sample. Larger studies are needed to further delineate SIP risk from the interaction of peripartum maternal medication with early postnatal therapies and disease pathophysiology. Key Points Perinatal indomethacin is associated with SIP in preterm infants born at less than 26 weeks. Temporal proximity of prenatal/postnatal medication exposure matters. Indomethacin and Hydrocortisone the risks, benefits, and timing related to SIP. [ABSTRACT FROM AUTHOR]

The modified scale scores the exam completeness, image labeling accuracy, image optimization, pathology detection, and agreement with the sonographer's interpretation. This project aims to adapt the adult Assessment of Competency in Thoracic Sonography (ACTS) Scale to pediatric and neonatal lung ultrasound (LUS) images. [Extracted from the article]

Abstract: Wnt signaling is critical for cell fate specification and cell differentiation in many organs, but its function in pulmonary neuroendocrine cell (PNEC) differentiation has not been fully addressed. In this study, we examined the role of canonical Wnt signaling by targeting the gene for Adenomatous Polyposis Coli (Apc), which controls Wnt signaling activity via mediating phosphorylation of beta-catenin (Ctnnb). Targeting the Apc gene in lung epithelial progenitors by Nkx2.1-cre stabilized Ctnnb and activated canonical Wnt signaling. Apc deficiency altered lung epithelial cell fate by inhibiting Clara and ciliated cell differentiation and activating Uchl1, a marker of neuroendocrine cells. Similar to PNEC in normal lung, Uchl1positive cells were innervated. In mice with targeted inactivation of Ctnnb by Nkx2.1-cre, PNEC differentiation was not interrupted. These indicate that, after lung primordium formation, Wnt signaling is not essential for PNEC differentiation; however, its over-activation promotes PNEC features. Interestingly, Nkx2.1 was extinguished in Apc deficient epithelial progenitors before activation of Uchl1. Examination of Nkx2.1 null lungs suggested that early deletion of Nkx2.1 inhibits PNEC differentiation, while late repression does not. Nkx2.1 was specifically inhibited in Apc deficient lungs but not in Ctnnb gain-of-function lungs indicating a functional difference between Apc deletion and Ctnnb stabilization, both of which activate Wnt signaling. Further analysis revealed that Apc deficiency led to increased TGF-beta signaling, which inhibited Nkx2.1 in cultured lung endodermal explants. In contrast, TGF-beta activity was not increased in Ctnnb gain-of-function lungs. Therefore, our studies revealed an important mechanism involving Apc and TGF-beta signaling in regulating the key transcriptional factor, Nkx2.1, for lung epithelial progenitor cell fate determination. [Copyright &y& Elsevier]

Phyllodes tumours (PTs) of the breast are true biphasic neoplasms within which interactions between the epithelium and stroma are critical for tumour development and progression. Despite numerous studies reporting the results of ancillary marker investigations in PTs, the current histological grading systems remain unreliable at predicting clinical outcome even when supplemented by these markers. As a consequence, there has been much interest in the prospect of using molecular/genetic techniques to develop a more robust "grading" system. This review focuses on recent cytogenetic and molecular studies investigating the pathogenesis of PTs and those correlating molecular findings with clinicopathological features of the tumours. Recent data highlight that intratumoural genetic heterogeneity is common in PTs and may account for the reported lack of correlation between histological grading and clinical behaviour. The entire spectrum of molecular aberrations in PTs are yet to be fully defined, however recent array-based studies using comparative genomic hybridisation have reported that copy number changes increase with the progression from benign PT to malignancy. Tumour recurrence and progression is likely to reflect the presence of under-recognised subclones. p16INK4a (CDKN2A) inactivation also appears to be important in PT pathogenesis. Further additional studies will be required to identify and validate new prognostic markers and therapeutic targets in order to improve the diagnosis, classification, prediction of outcome and management of patients with this rare neoplasm. Data generated from modern sequencing technologies are likely to provide new insights into the disease and assist in this endeavour. [ABSTRACT FROM AUTHOR]

Alveolar capillary dysplasia (ACD) is a congenital, lethal disorder of the pulmonary vasculature. Phosphatase and tensin homologue deleted from chromosome 10 (Pten) encodes a lipid phosphatase controlling key cellular functions, including stem/progenitor cell proliferation and differentiation; however, the role of PTEN in mesodermal lung cell lineage formation remains unexamined. To determine the role of mesodermal PTEN in the ontogeny of various mesenchymal cell lineages during lung development, we specifically deleted Pten in early embryonic lung mesenchyme in mice. Pups lacking Pten died at birth, with evidence of failure in blood oxygenation. Analysis at the cellular level showed defects in angioblast differentiation to endothelial cells and an accompanying accumulation of the angioblast cell population that was associated with disorganized capillary beds. We also found decreased expression of Forkhead box protein F1 (Foxf1), a gene associated with the ACD human phenotype. Analysis of human samples for ACD revealed a significant decrease in PTEN and increased activated protein kinase B (AKT). These studies demonstrate that mesodermal PTEN has a key role in controlling the amplification of angioblasts as well as their differentiation into endothelial cells, thereby directing the establishment of a functional gas exchange interface. Additionally, these mice could serve as a murine model of ACD. [ABSTRACT FROM AUTHOR]