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Objective This study aimed to describe our experience with universal urine drug screening (UDS) with rapid confirmation (RC) via liquid chromatography mass spectrometry (LC-MS) before infant's discharge, in efforts to increase detection of neonates at risk of neonatal opioid withdrawal syndrome (NOWS) while reducing patient burden related to false positive results. Study Design Two-phase retrospective study of all pregnant women admitted to our labor and delivery (L&D) unit before (phase 1, April 2018–March 2019) and after (phase 2, October 2019–September 2020) RC of UDS was initiated. Urine samples were obtained on admission and screened for drugs using an enzyme immunoassay with positive results reflexed to confirmation via LC-MS. The turnaround time for LC-MS was 1 week in phase 1 and 24 hours in phase 2. For mothers with positive LC-MS confirmation, the infant's meconium was sent for drug screening. Positive results were determined to be true or false positive based on urinary LC-MS results. The primary outcome was the rate of opioid-positive mothers who were unanticipated. The secondary outcome was the difference in rate of neonates who were observed for NOWS, before and after implementation of RC with LC-MS. Results In phase 2, a total of 2,395 deliveries occurred of which 2,122 (88.6%) had available UDS results. Fifty-two (2.5%) women had a positive UDS for at least one drug with LC-MS confirmation. Of those, 25 were true positive and 27 were false positive. Twenty-one (84%) true positive mothers were taking opioids and 8 (37%) of them were unanticipated positives. Among mothers with positive UDS for opioids, the neonatal observation rate for development of NOWS was 100% (22/22) and 48% (21/44) before and after implementation of LC-MS RC, respectively. Conclusion Universal UDS and LC-MS RC in L&D may improve detection of unanticipated positive mothers whose infants are at risk of NOWS. RC of positive results allows intervention only for confirmed cases. Key Points Universal UDS can detect more infants at risk of NOWS. Rapid confirmation of positive UDS reduces burden. Only confirmed infants should be observed in the neonatal intensive care unit. Child Protective Services should only be notified of confirmed opioid-positive results. [ABSTRACT FROM AUTHOR]

Tempol is an amphipathic radical nitroxide (N) that acutely reduces blood pressure (BP) and heart rate (HR) in the spontaneously hypertensive rat (SHR). We investigated the hypothesis that the response to nitroxides is determined by SOD mimetic activity or lipophilicity. Groups (n = 6-10) of anesthetized SHRs received graded intravenous doses of Ns: tempol (T), 4-amino-tempo (AT), 4-oxotempo (OT), 4-trimethylammonium-2,2,6,6-tetramethylpiperidine-1-oxyl iodide (CAT-1), 3-carbamoyl-proxyl (3-CP), or 3-carboxyproxyl (3-CTPY). Others received native or liposomal (L) Cu/Zn SOD. T and OT are uncharged, AT is positively charged and cell-permeable, and CAT-1 is positively charged and cell-impermeable. 3-CP and 3-CTPY have five-member pyrrolidine rings, whereas T, AT, OT, and CAT-1 have six-member piperidine rings. T and AT reduced mean arterial pressure (MAP) similarly (-48 [+ or -] 2 mmHg and -55 [+ or -] 8 mmHg) but more (P < 0.05) than OT and CAT-1. 3-CP and 3-CTPY were ineffective. The group mean change in MAP with piperidine Ns correlated with SOD activity (r = -0.94), whereas their E[D.sub.50] correlated with lipophilicity (r = 0.89). SOD and L-SOD did not lower BP acutely but reduced it after 90 min (-32 [+ or -] 5 and -31 [+ or -] 6 mmHg; P < 0.05 vs. vehicle). Pyrrolidine nitroxides are ineffective antihypertensive agents. The antihypertensive response to piperidine Ns is predicted by SOD mimetic action, and the sensitivity of response is by hydrophilicity. SOD exerts a delayed hypotensive action that is not enhanced by liposome encapsulation, suggesting it must diffuse to an extravascular site. tempol; superoxide dismutase; blood pressure; nitric oxide; hypertension.

We tested the hypothesis that superoxide anion ([O.sup.-.sub.2]*) generated in the kidney by prolonged angiotensin II (ANG II) reduces renal cortical P[o.sub.2] and the use of [O.sub.2] for tubular sodium transport ([T.sub.Na]:Q[O.sub.2]). Groups (n = 8-11) of rats received angiotensin II (ANG II, 200 ng x [kg.sup.-1] x [min.sup.-1] sc) or vehicle for 2 wk with concurrent infusions of a permeant nitroxide SOD mimetic 4-hydroxy-2,2,6,6-tetramethylpiperidine 1-oxyl (Tempol, 200 nmol x [kg.sup.-1] x [min.sup.-1]) or vehicle. Rats were studied under anesthesia with measurements of renal oxygen usage and P[O.sub.2] in the cortex and tubules with a glass electrode. Compared with vehicle, ANG II increased mean arterial pressure (107 [+ or -] 4 vs. 146 [+ or -] 6 mmHg; P < 0.001), renal vascular resistance (42 [+ or -] 3 vs. 65 [+ or -] 7 mmHg x [ml.sup.-1] x [min.sup.-1] x 100 [g.sup.-1] ; P < 0.001), renal cortical NADPH oxidase activity (2.3 [+ or -] 0.2 vs. 3.6 [+ or -]] 0.4 nmol [O.sup.-.sub.2]* x [min.sup.-1] x [mg.sup.-1] protein: P < 0.05), mRNA and protein expression for p[22.sup.phox] (2.1- and 1.8-fold respectively; P < 0.05) and reduced the mRNA for extracellular (EC)-SOD (-1.8 fold; P < 0.05). ANG II reduced the P[O.sub.2] in the proximal tubule (39 [+ or -] 1 vs. 34 [+ or -] 2 mmHg; P < 0.05) and throughout the cortex and reduced the [T.sub.Na]:Q[O.sub.2] (17 [+ or -] 1 vs. 9 [+ or -] 2 [micro]mol/[micro]mol; P < 0.001). Tempol blunted or prevented all these effects of ANG II. The effects of prolonged ANG II to cause hypertension, renal vasoconstriction, renal cortical hypoxia, and reduced efficiency of [O.sub.2] usage for [Na.sup.+] transport, activation of NADPH oxidase, increased expression of p[22.sup.phox], and reduced expression of EC-SOD can be ascribed to [O.sup.-.sub.2]* generation because they are prevented by an SOD mimetic. reactive oxygen species; superoxide dismutase; TEMPOL; nitroxides; NADPH oxidase; hypertension

Oxidative stress accompanies angiotensin (ANG) II infusion, but the role of ANG type 1 vs. type 2 receptors (A[T.sub.1]-R and A[T.sub.2]-R, respectively) is unknown. We infused ANG II subcutaneously in rats for 1 wk. Excretion of 8-isoprostaglandin [F.sub.2[alpha]] (8-Iso) and malonyldialdehyde (MDA) were related to renal cortical mRNA abundance for subunits of NADPH oxidase and superoxide dismutases (SODs) using real-time PCR. Subsets of ANG II-infused rats were given the A[T.sub.1]-R antagonist candesartan cilexetil (Cand) or the A[T.sub.2]-R antagonist PD-123,319 (PD). Compared to vehicle (Veh), ANG II increased 8-Iso excretion by 41% (Veh, 5.4 [+ or -] 0.8 vs. ANG II, 7.6 [+ or -] 0.5 pg/24 h; P < 0.05). This was prevented by Cand (5.6 [+ or -] 0.5 pg/24 h; P < 0.05) and increased by PD (15.8 [+ or -] 2.0 pg/24 h; P < 0.005). There were similar changes in MDA excretion. Compared to Veh, ANG II significantly (P < 0.005) increased the renal cortical mRNA expression of p[22.sup.phox] (twofold), Nox-1 (2.6-fold), and Mn-SOD (1.5-fold) and decreased expression of Nox-4 (2.1-fold) and extracellular (EC)-SOD (2.1-fold). Cand prevented all of these changes except for the increase in Mn-SOD. PD accentuated changes in p[22.sup.phox] and Nox-1 and increased p[67.sup.phox]. We conclude that ANG II infusion stimulates oxidative stress via A[T.sub.1]-R, which increases the renal cortical mRNA expression of p[22.sup.phox] and Nox-1 and reduces abundance of Nox-4 and EC-SOD. This is offset by strong protective effects of A[T.sub.2]-R, which are accompanied by decreased expression of p[22.sup.phox], Nox-1, and p[67.sup.phox]. candesartan; isoprostane; angiotensin receptor blocker; PD-123,319; malonyldialdehyde

Objective  The objective of this study was to evaluate the success and safety of an antimicrobial stewardship protocol for neonates admitted with respiratory distress at birth. Study Design  A retrospective cohort analysis of all infants admitted to the neonatal intensive care unit (NICU) with respiratory distress from January 2013 to February 2018 was conducted. In April 2016, an antimicrobial stewardship protocol was implemented, dividing neonates into two groups: maternal indications for delivery (no infectious risk factors for early-onset sepsis [EOS]) and fetal indications (risk factors present) for delivery. Neonates with risk factors for EOS were started on empiric antibiotics, those who lacked risk factors were observed. Paired sample t -test and descriptive statistics were used to compare the pre- and postprotocol implementation. Results  There were no missed cases of EOS in our study. Management with empiric antibiotics decreased from 95 to 41% of neonates with respiratory distress after initiation of the protocol. Newborns with a lower mean (±standard errors of the mean [SEM]) gestational age were more likely to receive empiric antibiotics (35.1 ± 0.4 [range: 23–42 weeks] vs. 37.7 ± 0.2 weeks [range: 24–42 weeks]; p  < 0.05). Similar findings were seen for neonates with lower mean birth weights (2,627 ± 77 [range: 390–5,440 g] vs. 3,078 ± 51 g [range: 620–6,260 g]; p  < 0.05). Conclusion  The antibiotic stewardship protocol safely reduces the administration of empiric antibiotics to symptomatic neonates without missing any cases of sepsis. Key Points Newborns born with respiratory distress often receive broad-spectrum antibiotics upon NICU admission. An antibiotic stewardship program was created for this population and considered perinatal risk factors for sepsis when determining whether antibiotics were indicated. This antibiotic stewardship program was safe and effective, significantly reducing antibiotic use without missing any cases of sepsis. [ABSTRACT FROM AUTHOR]

Biophysical profile (BPP) with ultrasound performed for a 32-year-old G5P3013 admitted at 31 weeks gestation with preterm, premature rupture of membranes (PPROM) noted an extracalvarial mass concerning for an encephalocele. Fetal MRI demonstrated edema over the occiput with no definable lesion visualized. Preterm labor requiring Cesarean delivery resulted in a live male neonate at 33 weeks gestation. An occipital mass was observed on neonatal physical exam. Postnatal ultrasound and MRI were consistent with cephalohematoma. This was surprising given the lack of vaginal delivery. We hypothesize that the occiput was positioned against the maternal ischial tuberosity and developed chronic trauma secondary to normal fetal movement over time, resulting in a cephalohematoma. Postnatal imaging confirmed this diagnosis as the mass gradually decreased and ultimately resolved. Although other etiologies are possible, this case emphasizes the need to consider cephalohematoma in the differential of CNS masses during pregnancy without abdominal trauma and/or vaginal delivery. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to evaluate the incidence of urinary tract infections (UTIs) in low birth weight (LBW) neonates and to evaluate the compliance of neonatal intensive care unit (NICU) providers in performing urine cultures as a part of late-onset sepsis (LOS) evaluations following an educational intervention., Study Design: A retrospective chart review for all LBW infants undergoing LOS evaluations was performed. An educational intervention was conducted to encourage NICU providers to perform urine cultures in LOS evaluations. Prospective chart reviews were conducted following the intervention to assess compliance with the urine culture directive and the incidence of UTIs before and after the intervention., Results: Rate of UTIs among LBW neonates was 1.3% for the entire study period and typical uropathogens were the cause. UTIs were found concurrently with bacteremia in only 33.3% of cases and showed a predilection for male infants when analyzing based on the number of infections. Urine cultures were performed in 20% of LOS evaluations prior to our educational intervention and increased to 57% ( p  < 0.0001) postintervention., Conclusion: An educational intervention is effective at increasing the rate of obtaining urine cultures with LOS evaluations. Performing these cultures reveals that UTIs in LBW neonates are common without bacteremia and can be missed if they are omitted from LOS evaluations., Key Points: · UTIs occur often in preterm infants, especially boys.. · Education increases the performance of urine cultures.. · UTIs in preterm infants occur often without bacteremia.., Competing Interests: None declared., (Thieme. All rights reserved.)

Biophysical profile (BPP) with ultrasound performed for a 32-year-old G5P3013 admitted at 31 weeks gestation with preterm, premature rupture of membranes (PPROM) noted an extracalvarial mass concerning for an encephalocele. Fetal MRI demonstrated edema over the occiput with no definable lesion visualized. Preterm labor requiring Cesarean delivery resulted in a live male neonate at 33 weeks gestation. An occipital mass was observed on neonatal physical exam. Postnatal ultrasound and MRI were consistent with cephalohematoma. This was surprising given the lack of vaginal delivery. We hypothesize that the occiput was positioned against the maternal ischial tuberosity and developed chronic trauma secondary to normal fetal movement over time, resulting in a cephalohematoma. Postnatal imaging confirmed this diagnosis as the mass gradually decreased and ultimately resolved. Although other etiologies are possible, this case emphasizes the need to consider cephalohematoma in the differential of CNS masses during pregnancy without abdominal trauma and/or vaginal delivery.

Background: Parenteral nutrition-associated cholestasis (PNAC) has historically been a significant cause of morbidity and mortality in neonates undergoing parenteral feeding. Studies examining the causes of cholestasis in the PN-dependent neonate have produced a wide range of data, with some conflicting results. Increased protein/nonprotein calorie ratios, increased glucose concentrations, and increased lipid concentrations have all been implicated as possible causes of PNAC. However, these studies were done in the pre-TrophAmine (neonatal-specific amino acid parenteral nutrition [PN] formulation) era. With the introduction of TrophAmine, infants are now receiving higher concentrations of protein, often being advanced rapidly even when nonprotein calories may not be sufficiently advanced to meet the infants' caloric needs. To the best of our knowledge, no studies have been conducted to evaluate the protein/nonprotein calorie ratio as a cause of PNAC in the TrophAmine era., Methods: A retrospective chart review of 25 cholestatic and 25 noncholestatic PN-dependent premature neonates was conducted. All neonates weighed between 600 and 1000 g. Cholestasis was defined as a serum total bilirubin (TB) >or=2.0 mg/dL, with a serum direct bilirubin (DB) >or=20% of the TB. Neonates with major congenital anomalies or who underwent major surgery were excluded. PN macronutrient compositions were analyzed to examine if the different amounts of protein concentrations and protein/nonprotein calorie ratios played a role in the development of PNAC. Statistical analysis was performed using Student's t-tests. p Values < .05 were considered statistically significant., Results: All measured nutrition parameters did not differ significantly between the cholestatic and noncholestatic groups. Protein intake, the protein/nonprotein calorie ratio, and renal function as evaluated by blood urea nitrogen (BUN) and creatinine did not differ between the 2 study groups. The only parameters that differed significantly between the groups were the duration of PN therapy and length of hospital stay., Conclusions: Protein to nonprotein calorie ratio was not an etiology in the development of cholestasis in infants (600-1000 g) receiving PN. Renal function elicited not to have an impact on cholestasis status of these infants. Therefore, providing adequate protein calories should not be limited in this patient population, as suggested by previous studies in the pre-TrophAmine era. We found that increased duration of PN therapy and increased length of hospital stay were associated with PNAC.