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Background: Antistaphylococcal penicillins and cefazolin are the treatments of choice for methicillin-susceptible Staphylococcus aureus (MSSA) infections, requiring multiple doses daily. At Parkland, eligible uninsured patients with MSSA bloodstream infections (BSI) receive self-administered outpatient parenteral antimicrobial therapy (S-OPAT). Ceftriaxone was used in a cohort of S-OPAT patients for ease of once-daily dosing. Objective: A retrospective study was conducted to evaluate clinical outcomes for patients discharged with ceftriaxone versus cefazolin to treat MSSA BSI. Methods: A retrospective cohort noninferiority study design was used to assess treatment efficacy of ceftriaxone versus cefazolin among Parkland S-OPAT patients treated from April 2012 to March 2020. Demographic, clinical, and treatment-related adverse events data were collected. Clinical outcomes included treatment failure as defined by repeat positive blood culture or retreatment within 6 months, all-cause 30-day readmission rates, and central line–associated bloodstream infection (CLABSI) rates. Results: Of 368 S-OPAT patients with MSSA BSI, 286 (77.7%) received cefazolin, and 82 (22.3%) received ceftriaxone. Demographics and comorbidities were similar for both groups. There were no treatment failures in the ceftriaxone group compared with 4 (1%) in the cefazolin group ( P = 0.58). No difference in 30-day readmission rate between groups was found. The CLABSI rates were lower in ceftriaxone group (2%) compared with cefazolin (11%; P = 0.02). Limitations include retrospective cohort design. Conclusions: Ceftriaxone was found to be noninferior to cefazolin in this study. Our findings suggest that ceftriaxone is a safe and effective treatment of MSSA BSI secondary to osteoarticular or skin and soft tissue infections when used in the S-OPAT setting. Poster abstract: OFID on 2018 Nov; 5(Suppl 1): S316: doi: 10.1093/ofid/ofy210.894.

Infants born very preterm (≤32 weeks gestational age, GA) and very-low birth weight (≤1500 g; PT-VLBW) demonstrate high systolic blood pressure (SBP), renal dysfunction, and obesity at 6 months-3 years and in early adulthood. Their parallel measurement and progression during childhood is unclear.We reenrolled 62/120 patients originally seen at 1-3 years at 10-13 years and remeasured anthropometric indices, SBP, and serum creatinine (Cr) and cystatin C (cysC) to determine estimated glomerular filtration rate (eGFR). We selected Term-matched Controls at 10-13 years from the 2015-2016 NHANES database at a ratio of 2 Controls:1 Case (124:62).Reenrolled patients were predominantly Hispanic, birth weight 1073 ± 251 g, and GA at birth 28 ± 2 weeks. At 10-13 years, 45% were classified overweight/obese, 48% had SBP ≥ 90th centile (77% considered hypertensive), and 34% had low eGFR (90 mL minPT-VLBW infants seen at 1-3 years exhibit obesity, elevated SBP, and low eGFR in infancy and 10-13 years. Although the small sample size may limit conclusions, pediatricians should consider serial evaluations of PT-VLBW throughout childhood.The association between preterm birth and elevated blood pressure, renal dysfunction, and obesity in young adults begins as early as 1 year and persists at 10-13 years of age. This is the first study reporting serial measurements of blood pressure, renal function, and obesity from infancy to preadolescence in children born very preterm. Fifty-seven percent of preterm 1-3 year olds have persistent low estimated glomerular filtration rate associated with hypertension at 10-13 years. Clinicians should consider serial evaluations of blood pressure, renal function, and obesity throughout infancy and childhood in all preterm births.

We evaluated the impact of patient education over opioid use, storage, and disposal on opioid handling patterns of palliative and chronic nonmalignant pain patients. We compared patient surveys before and after education and conducted further analysis for individual clinics due to group differences found prior to education. A total of 100 patients were included. After education, more patients reported never sharing their prescription opioid (95% vs. 66%

There is limited data on non-adherence for surgical treatment in non-melanoma skin cancer (NMSC) patients. The objective of this single-center, retrospective cohort study is to compare rates of non-adherence of surgical treatment options, determine factors associated with non-adherence, and identify barriers for non-adherence. All adult patients with NMSC (> 18 years) seen between 2015 and 2017 recommended surgical treatment (surgical excision and electrodessication and curettage (ED&C) or Mohs surgery) were eligible. Non-adherence was defined as not completing recommended treatment and reasons for non-adherence were collected. Out of 427 patients that met inclusion criteria, patients recommended surgical excision and ED&C had a lower non-adherence rate of 3.4% compared to those recommended Mohs (11.4%) (p = 0.006). Factors associated with non-adherence included self-pay patients (19.07% adherent vs. 43.24% non-adherent, p = 0.004). Multivariate logistic regression analysis confirmed that Mohs patients were more likely to be non-adherent (odds ratio (OR) = 3.839, 95% confidence interval (CI) (1.435-10.270), p = 0.007) compared to surgical excision and ED&C patients. Males were more likely to be non-adherent (OR = 2.474, 95% CI (1.105-5.542), p = 0.028) to females, and self-pay patients were more likely to be non-adherent than those with other payers (OR = 3.050, 95% CI (1.437-6.475), p = 0.004). Of the 37 patients who were non-adherent, the most common reasons were loss to follow-up (46%), social reasons (41%), medical reasons (38%), and financial reasons (22%). There was a significant difference in non-adherence rates between surgical treatments for NMSCs in our cohort. Our study suggests the need for future interventional studies that implement strategies and patient education to decrease non-adherence rates.

Although electrocardiogram (ECG) can detect heart rate (HR) faster compared to pulse oximetry, it remains unknown if routine use of ECG for delivery room (DR) resuscitation reduces the time to stabilization in preterm infants. Neonates

Objective To assess if the adjusted odds of low composite cognitive Bayley-III scores changed after implementing a single-institution quality improvement (QI) project designed to decrease discharge Z-scores for weight, body mass index (BMI), and weight-for-length, but not length or fronto-occipital circumference (FOC) in infants 23–28 weeks gestational age (GA). Methods Compare Bayley-III outcomes at ≥18 months corrected age (postnatal age adjusted for prematurity) in infants tested before (Epoch-1) and after (Epoch-2) QI implementation. Results Bayley testing was available in 134/156 infants (86%) in Epoch-1 and 139/175 (79%) in Epoch-2. There was no change in frequency of low (

To assess the relationship of size for age with zinc deficiency in extremely low gestational age (GA) infants (23-28 weeks, ELGANs) who had insufficient linear growth despite optimizing other nutrients and to analyze changes in fronto-occipital circumference (FOC), weight and length with zinc supplementation.Retrospective cohort study.Among 302 ELGANs, a serum zinc concentration was obtained in 52 with insufficient linear growth (17%). Zinc deficiency (serum concentration0.74 mcg/ml) was diagnosed in 8 of 24 (33%) small for GA (SGA) compared to 35 of 278 (13%) non-SGA infants (P = 0.01). Zinc supplementation for2 weeks improved FOC growth to discharge or 50 weeks postmenstrual age in infants with Zn deficiency. However, neither linear growth nor weight gain improved with Zn supplementation.Zinc deficiency was diagnosed in 14% ELGANs in this cohort. Zinc supplementation for2 weeks improved FOC growth but not linear growth or weight gain.

To assess whether in very preterm infants (1) body mass index (BMI) Z-score and weight-for-length (WtFL) Z-score at 1 year of age and (2) head growth from discharge to 1 year are associated with breastfeeding at discharge and the age of onset and type of complementary foods. Observational cohort study. Infants started on only ready-made complementary (RMC) feedings at ≤26 weeks adjusted age had the highest adjusted BMI Z-score and WtFL Z-score at 1 year of age. Adjusted change in fronto-occipital circumference was highest in infants either discharged on breastmilk or receiving home-made complementary food with/without RMC (HMM) at ≤26 weeks adjusted age. Infants started on RMC ≤26 weeks adjusted age had the highest BMI Z-score and WtFL Z-score at 1 year. Head growth from discharge to 1 year was highest in infants either discharged on breastmilk or receiving HMM at ≤26 weeks adjusted age.

In preterm neonates fed human milk, fortification may be adjusted by (1) optimization, based on growth rate and serum nutrient analyses, or (2) individualization, based on serial milk nutrient analyses. The primary aim was to determine whether individualized plus optimized nutrition (experimental) improves velocity of weight gain and linear growth from birth to endpoint (36 weeks postmenstrual age or discharge) when compared with optimized nutrition alone (controls). Double-blinded parallel group randomized trial in 120 neonates

Background Prior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a syringe bolus push. However, intravenous drip infusions subsequently became the standard of care. Puerto Rico is the largest supplier of IV fluid bags and in the aftermath of Hurricane Maria, there was a nationwide fluid bag shortage. This shortage required stewardship measures to maintain the operation of the self-administered outpatient parenteral antimicrobial therapy (OPAT) program at Parkland Health. Methods Parkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV syringe bolus push (IVP) instead of an IV-drip infusion. Medications deemed appropriate were transitioned to IVP. The hospital EMR was used to identify patients discharged to the OPAT clinic using all methods of parenteral drug delivery. Data was collected for patient demographics, patient satisfaction, and clinical outcomes. Finally cost of care was calculated for IVP and IV drip administration. Results One-hundred and thirteen self-administered IVP and 102 self-administered IV drip treatment courses were identified during the study period. Individuals using IVP had a statistically significant decrease in hospital length of stay. Patient satisfaction was greater with IVP and IVP saved 504 liters of normal saline resulting in a savings of $43,652 over 6 months. The 30-day readmission rate and mortality were similar. Conclusion The abrupt IV fluid shortage following a natural disaster led to implementation of a high value care model that improved efficiency, reduced costs, and did not affect safety or efficacy.

Background To determine the association of placental pathology, including multiple placental lesions, with the occurrence and severity of bronchopulmonary dysplasia (BPD), death, and neurodevelopmental impairment (NDI) in preterm infants. Method A retrospective cohort study of neonates

We previously reported an increase in pneumothorax after implementing delivery room (DR) continuous positive airway pressure (CPAP) for labored breathing or persistent cyanosis in ≥35-week gestational age (GA) neonates unexposed to DR-positive pressure ventilation (DR-PPV). We hypothesized that pneumothorax would decrease after de-implementing DR-CPAP in those unexposed to DR-PPV or DR-OIn a retrospective cohort excluding DR-PPV the primary outcome was DR-CPAP-related pneumothorax (1st chest radiogram, 1st day of life). In a subgroup treated by the resuscitation team and admitted to the NICU, the primary outcome was DR-CPAP-associated pneumothorax (1st radiogram, no prior PPV) without DR-PPV/OIn the full cohort, occurrence of DR-CPAP-related pneumothorax decreased after the intervention (11.0% vs 6.0%, P 0.001). In the subgroup, occurrence of DR-CPAP-associated pneumothorax decreased after the intervention (1.4% vs. 0.06%, P 0.001).The occurrence of CPAP-associated pneumothorax decreased after avoiding DR-CPAP in ≥35-week GA neonates without DR-PPV/O

ObjectivesVarious genetic polymorphisms have been associated with an increased risk of cutaneous lupus erythematosus (CLE). However, it is not fully known how often positive family histories occur in patients with CLE. The aims of this study are to determine the rate of positive family history among patients with CLE and to identify risk factors associated with positive family history.MethodsA retrospective cohort study was conducted among 338 patients with CLE seen in outpatient dermatology clinics in a tertiary referral centre in Dallas, Texas. The primary outcome was positive family history of CLE and/or SLE, as defined by the presence of self-reported CLE and/or SLE in first-degree or more distant relatives of a patient. Univariate analyses were performed to identify risk factors associated with positive family history of CLE and/or SLE in patients with CLE. Multivariable logistic regression analyses were performed to determine significant predictors of positive family history of CLE and/or SLE.Results34% (n=114) of patients reported positive family history of CLE and/or SLE. 7% (n=23) of patients with CLE had relatives with CLE, with 5% (n=18) having a first-degree relative with CLE. 30% (n=102) of patients with CLE had relatives with SLE, and 15% (n=52) had a first-degree relative with SLE. Black patients were more likely to have positive family history of CLE and/or SLE (OR 2.13, 95% CI 1.23 to 3.69, p=0.007).ConclusionsMore patients with CLE had positive family history of SLE than CLE. Black patients with CLE were more likely to have a relative with CLE and/or SLE. Providers can use this information to counsel patients with CLE on the risk of other family members having CLE and/or SLE. These data may help identify potentially new genetic polymorphisms associated with positive family history.

To test the inter-rater reliability of the modified Sarnat neurologic examination in preterm neonates and to correlate abnormalities with the presence of perinatal acidosis. Prospective study of 32–36 weeks’ gestational age infants admitted to the neonatal intensive care unit. Each infant had two Sarnat examinations performed at 0.8) except for Moro, while among all examiners agreement was very good (k > 0.7) except for both Moro and tone. Subgroup analysis at 32–34 weeks’ showed fair/poor Moro compared to excellent agreement at ≥35 weeks. Increasing abnormalities correlated with acidosis (r = −0.6, P

Patent ductus arteriosus (PDA) management varies widely among neonatologists. Lack of institution-specific evidence-based guidelines for therapeutic closure of PDA. Quality improvement project among infants

Fetal concentrations of GFAP and UCH-L1 are elevated in umbilical arterial (UmA) blood of neonates with birth asphyxia plus neonatal encephalopathy (NE), but their source and role of placental clearance/synthesis is unknown. Prospective cohort study of term neonates to (a) determine UmA and venous (UmV) blood concentrations of GFAP and UCH-L1 in term uncomplicated pregnancies and their placental synthesis and/or clearance and (b) compare UmA concentrations in uncomplicated pregnancies with those complicated by fetal hypoxia–asphyxia+NE. Three term groups were studied: uncomplicated cesarean delivery without labor (Group 1, n = 15), uncomplicated vaginal delivery with labor (Group 2, n = 15), and perinatal hypoxia–asphyxia+NE (Group 3, n = 8). UmA GFAP concentrations were lower in Group 1 vs. 2 (P = 0.02) and both demonstrated 100% placental clearance. In contrast, UmA and UmV UCH-L1 concentrations were not unaffected by labor. Group 3 UmA GFAP concentrations were 30- and 8-fold higher than Groups 1 and 2, respectively, P = 0.02, whereas UmA UCH-L1 concentrations were similar in all groups. UmA GFAP is derived from the fetus, and circulating levels, which are modulated by placental clearance, increase during uncomplicated labor and more so in the presence of fetal hypoxia–asphyxia+NE, providing a better biomarker than UCH-L1 for hypoxia–asphyxia+NE.

Although electrocardiogram (ECG) can detect heart rate (HR) faster compared to pulse oximetry, it remains unknown if routine use of ECG for delivery room (DR) resuscitation reduces the time to stabilization in preterm infants.Neonates31 weeks' gestation were randomized to either an ECG-displayed or an ECG-blinded HR assessment in the DR. HR, oxygen saturation, resuscitation interventions, and clinical outcomes were compared.During the study period, 51 neonates were enrolled. The mean gestational age in both groups was 28 ± 2 weeks. The time to stabilization, defined as the time from birth to achieve HR ≥100 b.p.m., as well as oxygen saturation within goal range, was not different between the ECG-displayed and the ECG-blinded groups [360 (269, 435) vs 345 (240, 475) s, p = 1.00]. There was also no difference in the time to HR ≥100 b.p.m. [100 (75, 228) vs 138 (88, 220) s, p = 0.40] or duration of positive pressure ventilation (PPV) [345 (120, 558) vs 196 (150, 273) s, p = 0.36]. Clinical outcomes were also similar between groups.Although feasible and safe, the use of ECG in the DR during preterm resuscitation did not reduce time to stabilization.Although feasible and apparently safe, routine use of the ECG in the DR did not decrease time to HR100 b.p.m., time to stabilization, or use of resuscitation interventions such as PPV for preterm infants31 weeks' gestational age. This article adds to the limited randomized controlled trial evidence regarding the impact of routine use of ECG during preterm resuscitation on DR clinical outcomes. Such evidence is important when considering recommendations for routine use of the ECG in the DR worldwide as such a recommendation comes with a significant cost burden.

There is limited data on non-adherence for surgical treatment in non-melanoma skin cancer (NMSC) patients. The objective of this single-center, retrospective cohort study is to compare rates of non-adherence of surgical treatment options, determine factors associated with non-adherence, and identify barriers for non-adherence. All adult patients with NMSC ( 18 years) seen between 2015 and 2017 recommended surgical treatment (surgical excision and electrodessication and curettage (EDC) or Mohs surgery) were eligible. Non-adherence was defined as not completing recommended treatment and reasons for non-adherence were collected. Out of 427 patients that met inclusion criteria, patients recommended surgical excision and EDC had a lower non-adherence rate of 3.4% compared to those recommended Mohs (11.4%) (p = 0.006). Factors associated with non-adherence included self-pay patients (19.07% adherent vs. 43.24% non-adherent, p = 0.004). Multivariate logistic regression analysis confirmed that Mohs patients were more likely to be non-adherent (odds ratio (OR) = 3.839, 95% confidence interval (CI) (1.435-10.270), p = 0.007) compared to surgical excision and EDC patients. Males were more likely to be non-adherent (OR = 2.474, 95% CI (1.105-5.542), p = 0.028) to females, and self-pay patients were more likely to be non-adherent than those with other payers (OR = 3.050, 95% CI (1.437-6.475), p = 0.004). Of the 37 patients who were non-adherent, the most common reasons were loss to follow-up (46%), social reasons (41%), medical reasons (38%), and financial reasons (22%). There was a significant difference in non-adherence rates between surgical treatments for NMSCs in our cohort. Our study suggests the need for future interventional studies that implement strategies and patient education to decrease non-adherence rates.

BACKGROUND AND OBJECTIVES Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks’ gestational age (GA). METHODS A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks’ GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre–OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS Of the 216 infants ≤29 weeks’ GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks’ GA (46% vs 3%; P < .01). CONCLUSIONS Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.

BackgroundAntibiotic exposure in term infants has been associated with later obesity. Premature, very-low-birth-weight (birth weight ≤ 1500 g) infants in the neonatal intensive care unit frequently are exposed to antibiotics. Our hypothesis was that in preterm infants, there is a positive linear and dose-dependent relationship between antibiotic exposure and growth from birth through 12 months’ corrected age.MethodsRetrospective analysis of prospectively collected data of all antibiotic use among inborn, preterm (≤32 weeks’ gestation), very-low-birth-weight infants admitted to the neonatal intensive care unit at Parkland Memorial Hospital and followed in the Low Birth Weight Clinic at Children’s Medical Center, Dallas, TX. Antibiotic use was quantified by days of therapy which was compared with weight and length parameters at birth, 36 weeks’ postmenstrual age, and 2, 4, 6, and 12 months’ corrected age. The change in weight and length z-scores from birth to all subsequent age points was calculated. Stepwise multivariate regression analysis was performed to determine predictors of weight, length, and weight-for-length delta z-scores from birth to each subsequent age point.ResultsDuring the 18-month study, 161 infants received a median of 11 (IQR, 5.5–19.5) antibiotic days of therapy which was not associated with weight or length delta z-scores from birth through 12 months’ corrected age.ConclusionAssociation of prolonged antibiotic use and neonatal morbidities and mortality may override the potential association with increased weight gain in the NICU and beyond.

The prevalence of autism spectrum disorders (ASD) is 5-fold higher in preterm (PT) infants born ≤28 weeks gestational age (GA) as compared to the general population. The relationship between placental pathologic lesions and ASD in PT infants has not been studied.The objective of this study was to determine the association of placental pathology with the occurrence of ASD in PT infants born ≤28 weeks GA.A matched case-control study to identify confirmed ASD cases (n = 16) and matched controls (n = 48) born at Parkland Hospital between January 2012 and December 2015. Patients were matched using known variables associated with increased risk of ASD in PT infants. Placental histology from all births was reviewed.Children with ASD had 2-fold greater incidence of multiple placental pathologic lesions vs. matched controls [11/16 (69%) vs.16/48 (33%), respectively; P = 0.01]. In contrast, single placental pathologic lesions were not associated with ASD [5/16 (31%) vs. 21/48 (43%), respectively; P = 0.1].In this study, we have demonstrated an association between the increasing complexity of histologic placental lesions and the later risk for ASD in infants born ≤28 weeks GA. Thus, placental pathology findings may be valuable in further understanding the prenatal pathologic processes underlying ASD in PT infants.PT infants with ASD have a 2-fold greater incidence of multiple placental pathologies. This is the first study to report an association between the complexity of histologic placental lesions and later risk of ASD in infant born extremely PT (i.e., ≤28 weeks GA). This study reiterates the importance of examining placental pathologic lesions, since placental evidence of antenatal insults correlates with postnatal morbidities and mortality in PT infants.

In preterm neonates fed human milk, fortification may be adjusted by (1) optimization, based on growth rate and serum nutrient analyses, or (2) individualization, based on serial milk nutrient analyses. The primary aim was to determine whether individualized plus optimized nutrition (experimental) improves velocity of weight gain and linear growth from birth to endpoint (36 weeks postmenstrual age or discharge) when compared with optimized nutrition alone (controls).Double-blinded parallel group randomized trial in 120 neonates29 weeks gestational age (GA) or35 weeks and small for GA (birth weight 10th centile).Weight-gain velocity (13.1 ± 2.1, n = 57 controls, vs. 13.0 ± 2.6 g kgIndividualized plus optimized nutrition does not improve weight gain, linear growth, or weight/length disproportion at endpoint versus optimized nutrition alone.

To assess whether in very preterm infants (1) body mass index (BMI) Z-score and weight-for-length (WtFL) Z-score at 1 year of age and (2) head growth from discharge to 1 year are associated with breastfeeding at discharge and the age of onset and type of complementary foods.Observational cohort study.Infants started on only ready-made complementary (RMC) feedings at ≤26 weeks adjusted age had the highest adjusted BMI Z-score and WtFL Z-score at 1 year of age. Adjusted change in fronto-occipital circumference was highest in infants either discharged on breastmilk or receiving home-made complementary food with/without RMC (HMM) at ≤26 weeks adjusted age.Infants started on RMC ≤26 weeks adjusted age had the highest BMI Z-score and WtFL Z-score at 1 year. Head growth from discharge to 1 year was highest in infants either discharged on breastmilk or receiving HMM at ≤26 weeks adjusted age.

Chronic urticaria (CU) is urticaria that has been present continuously or intermittently for at least 6 weeks. Although the prevalence and characteristics of CU are well established, little is known about recurrent CU (RCU).We sought to establish a definition, determine the frequency, and evaluate risk factors for RCU.A retrospective chart review of adult patients with CU evaluated at the University of Texas Southwestern allergy and immunology clinic was performed. RCU was defined as CU recurring at least 6 months after cessation of controller therapy and resolution of prior CU symptoms. Charts were reviewed for symptom resolution and recurrence, subtypes of CU (idiopathic, physical, and urticarial vasculitis), and medication usage (first-line agents, alternative agents, and steroid dependence).Forty-five of 341 patients (13%) had RCU. The recurrence group had a higher frequency of alternative agent use at 57.8% (n = 26) compared with the nonrecurrence group at 34.8% (n = 103), which was statistically significant (P.01). The rate of steroid dependence was similar in both groups (13.3% in the recurrence group vs 14.5%) and not statistically significant. Individuals exposed to anti-inflammatory agents, immunosuppressants, and omalizumab had a significantly higher relative risk of recurrence compared with those who only used first-line agents (relative risk [RR] 2.32, P.01; RR 2.69, P .01; and RR 2.18, P = .05, respectively).RCU occurs in approximately 13% of patients with CU in our clinic population. Alternative agent use and antihistamine refractoriness appear to place patients at increased risk for recurrence compared with first-line agent use alone.

Readmissions and emergency department (ED) visits after an index admission have been become a quality measure due to associations with poor outcomes and increased healthcare costs. Readmissions and ED encounters have been studied in a variety of conditions including epilepsy but have not been examined exclusively in psychogenic nonepileptic seizures (PNES). In this study we examined the rate of readmissions and ED visits after a discharge from an Epilepsy Monitoring Unit (EMU) in a safety net hospital. We also determined patient phenotypes that are associated with readmissions.This was a retrospective chart review study with index admission being a discharge from an EMU between January 1 and December 31 2016 with follow-up until August 31 2020. We obtained data regarding demographics, medical and psychiatric history, and social history and treatment interventions. Our outcome variables were both all-cause and seizure-related hospital readmissions and ED visits 30 days following the index discharge and readmissions and ED visits 30 days thereafter.Eleven of 122 patients (9%) had a non-seizure-related ED visit and/or hospitalization within 30 days of index discharge while 45 (37%) had re-contact with the health system thereafter for non-seizure-related issues. Seven of 122 patients (6%) had a seizure-related ED visit or hospital readmission within 30 days of discharge. Twenty-eight (23%) had a seizure-related readmission or ED visit after 30 days. Of these 28, 4 patients had been to an ER within 7 days of EMU discharge. The majority of subsequent encounters with the healthcare system were through the ED (n = 38) as compared to hospital (n = 10) and EMU readmissions (n = 9). On bivariate statistical analysis, charity or self-pay insurance status (p 0.01), homelessness (p 0.01), emergent EMU admission on index admission (p 0.01), history of a psychiatric diagnosis (p 0.02), and ED encounters 12 months prior to admission (p 0.01) were significantly associated with readmission; however, on multivariate analysis only charity insurance status was a significant predictor.In this study of readmissions and ED visits after discharge with a diagnosis of PNES at a safety net hospital, we found a seizure-related readmission rate of approximately 6% in 30 days and 23% thereafter with the majority of re-contact with the hospital being in the ED. On multi-variate analysis insurance status was a significant factor associated with readmission and ED visits. Our future research directions include examining referrals and treatment completion at the hospital's PNES clinic as well as creating a risk score to better identify patients with PNES at risk of readmission.

Background There is growing evidence to support an association between placental inflammation and neurological sequelae of preterm infants. The goal of this study is to evaluate the relationship between placental pathology, post-natal Doppler cerebral resistive indices (RI’s), and intraventricular hemorrhage (IVH) in premature infants. Methods In a retrospective cohort study, preterm infants born between 23 0/7 and 32 6/7 weeks’ gestation at Parkland Hospital were examined with placental pathology and serial ultrasound Doppler to evaluate for the primary outcome of IVH and death. Results A total of 255 infants were included, and 166 (65%) had at least one significant placental pathology, most commonly chorioamnionitis. Infants with placental pathologies were significantly more likely to have mothers with clinical chorioamnionitis and to have lower gestational ages. There was no observed association between placental pathology and IVH or death. Secondary analysis demonstrated that resistive indices obtained from the first and second head ultrasounds were not different in infants with IVH. Conclusion In this study, we observed a high rate of placental pathologies but no alterations in cerebral indices on ultrasound, or differences in rates of IVH or death. Additional studies are necessary to delineate the relationship between placental pathology, white matter brain injury, and outcomes.

BACKGROUND: In 2011, the Neonatal Resuscitation Program (NRP) added consideration of continuous positive airway pressure (CPAP) for spontaneously breathing infants with labored breathing or hypoxia in the delivery room (DR). The objective of this study was to determine if DR-CPAP is associated with symptomatic pneumothorax in infants 35 to 42 weeks’ gestational age. METHODS: We included (1) a retrospective birth cohort study of neonates born between 2001 and 2015 and (2) a nested cohort of those born between 2005 and 2015 who had a resuscitation call leading to admission to the NICU and did not receive positive-pressure ventilation. RESULTS: In the birth cohort (n = 200 381), pneumothorax increased after implementation of the 2011 NRP from 0.4% to 0.6% (P < .05). In the nested cohort (n = 6913), DR-CPAP increased linearly over time (r = 0.71; P = .01). Administration of DR-CPAP was associated with pneumothorax (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 4.4–6.8); the OR was higher (P < .001) in infants receiving 21% oxygen (OR: 8.5; 95% CI: 5.9–12.3; P < .001) than in those receiving oxygen supplementation (OR: 3.5; 95% CI: 2.5–5.0; P < .001). Among those with DR-CPAP, pneumothorax increased with gestational age and decreased with oxygen administration. CONCLUSIONS: The use of DR-CPAP is associated with increased odds of pneumothorax in late-preterm and term infants, especially in those who do not receive oxygen in the DR. These findings could be used to clarify NRP guidelines regarding DR-CPAP in late-preterm and term infants.

Patent ductus arteriosus (PDA) management varies widely among neonatologists.Lack of institution-specific evidence-based guidelines for therapeutic closure of PDA.Quality improvement project among infants30 weeks gestational age (GA) designed to determine whether the odds of therapy for closing the PDA, adjusted for GA, decreased after implementing evidence-based guidelines.Implementation of guidelines with conservative approach to PDA management.The frequency of PDA treatment decreased from 446/1125 (40%) in Epoch 1 to 96/482 (20%) in Epoch 2. PDA treatment was more frequent in neonates 23-26 weeks GA than those of 27-29 weeks GA (43% vs. 28%, respectively). Among 542 infants receiving indomethacin for PDA, 25% had subsequent ligation; the odds of ligation after indomethacin were lower in neonates 27-29 weeks GA and decreased during Epoch 2.The frequency of medical and surgical treatment for therapeutic closure of PDA decreased after implementing evidence-based treatment guidelines.

BACKGROUND AND OBJECTIVES: Avoidance of delivery room intubation (DRI) reduces death or bronchopulmonary dysplasia (BPD) in preterm neonates. Our objective with this quality improvement project was to decrease DRI rates by improving face mask positive pressure ventilation (Fm-PPV) among infants born ≤29 weeks’ gestation. METHODS: Key drivers of change were identified from a retrospective review of resuscitation records. A resuscitation bundle to optimize Fm-PPV including the use of a small round mask and end-tidal CO2 detectors, increasing peak inspiratory pressure when indicated, and debriefing after each intubation were implemented in consecutive plan-do-study-act cycles. The DRI rate was tracked by using a control chart. Resuscitation practice and outcomes of pre–quality improvement cohort (QIC) (January 2014–September 2015) were compared with post-QIC (October 2015–December 2016). RESULTS: Of the 314 infants who were resuscitated, 180 belonged to the pre-QIC and 134 to the post-QIC. The antenatal steroid administration rate was higher in the post-QIC (54% vs 88%). More infants in the post-QIC had resolution of bradycardia after Fm-PPV (56% vs 77%, P = .02). Infants in the post-QIC had lower DRI rates (58% vs 37%, P < .01), lower need for mechanical ventilation (85% vs 70%, P < .01), lower rates of BPD (26% vs 13%, P < .01), and severe retinopathy of prematurity (14% vs 5%, P = .01). Rates of DRI, BPD, and severe retinopathy of prematurity remained lower even after controlling for the potential confounders. CONCLUSIONS: Implementation of a resuscitation bundle decreased the DRI rate and improved outcomes of preterm infants.

Background Albumin after large volume paracentesis (LVP) reduces paracentesis-induced circulatory dysfunction (PICD). The most efficacious dose of albumin for LVP is unclear. Objective To evaluate the impact of implementing a standardized LVP order set on albumin utilization and patient outcomes. Methods This is a retrospective review of patients with ascites due to cirrhosis who received a therapeutic paracentesis at a large, academic institution. Primary outcome was amount of albumin used prior to and after order set implementation. Albumin doses were standardized in the order set to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L). Patient outcomes were rates of hyponatremia, renal impairment, and hypotension. Results There were 100 patients included in each arm of the final analysis. Patients prior to order set implementation received a higher amount of albumin per liter removed compared to those post-implementation (8.3 g/L vs 6.5 g/L, respectively; P < .01). There were no significant differences between groups in absolute changes in serum sodium (0 mEq/L vs −1 mEq/L, P = .64), serum creatinine (0.06 mg/dL vs 0.05 mg/dL, P = .94), or systolic blood pressure (−4 mm Hg vs −3 mm Hg, P = .96). There were no differences between groups in rates of hyponatremia (1.6% vs 6.6%, P = .21), renal impairment (11.3% vs 11.5%, P = .97), or hypotension (17.4% vs 17.6%, P = .97). Conclusions Use of an order set to guide albumin dosing based on amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given with no difference in adverse effects.

To develop a prediction model to identify infants admitted on continuous positive airway pressure (CPAP) requiring intubation within seventy-two hours of life (HOL). Infants born ≤29 weeks’ gestational age between 2013 and April 2018 were randomly assigned to either a modeling cohort (MC) or a validation cohort (VC) in a 2:1 ratio. Variables available within two HOL were compared between the CPAP failure group (CFG) and the CPAP success group (CSG). Of the 189 infants in the MC, 50% failed CPAP. Compared to CSG, infants in the CFG had lower antenatal steroid exposure, birth weight, higher radiographic severe respiratory distress syndrome (RDS) and fraction of inspired oxygen (FiO2). A forward stepwise logistic regression modeling in both MC and VC showed that FiO2 >0.3 and radiographic severe RDS predicted CPAP failure. FiO2 >0.3 within two HOL and radiographic severe RDS predicts CPAP failure in preterm infants.

Objectives To compare immediate cessation of nasal continuous positive airway pressure (NCPAP) vs a stepwise decrease in pressure on the duration of NCPAP therapy in infants born prematurely. Study design A single center study in infants 230-326 weeks of gestational age. NCPAP was stopped either at 5 cm H2O (control) or 3 cm H2O after a stepwise pressure wean (wean) using defined stability and failure criteria. Primary outcome is total NCPAP days. Results We enrolled 226 infants; 116 were randomly assigned to control and 110 to the wean group. There was no difference in the total NCPAP days between groups (median [25th, 75th percentiles] 16 [5, 36] vs 14 [7, 33] respectively). There were no differences between groups in secondary outcomes, including duration of hospital stay, critical care days, and oxygen supplementation. A higher proportion of control infants failed the initial attempt to discontinue NCPAP (43% vs 27%, respectively; P Conclusions Discontinuation of NCPAP after a gradual pressure wean to 3 cm H2O did not decrease the duration of NCPAP therapy compared with stopping from 5 cm H2O in infants ≤32 weeks of gestational age. However, weaning decreased failed initial attempts to stop NCPAP, particularly among infants Trial registration Clinicaltrials.gov: NCT02064712 .

Vulnerable Child Syndrome (VCS) occurs in the setting in which a child recovers from a life-threatening illness, as result of which the parent develops heightened parental perceptions of child vulnerability (PPCV). This leads to a pattern of overprotective parenting which may result in adverse neurodevelopmental and behavioral outcomes in the child over time. Parents of premature infants have been shown to be at increased risk of developing raised PPCV while their infants may develop symptoms of VCS. The PreVNT trial is a randomized controlled trial designed to test the efficacy of a 5-session manualized Cognitive Behavioral Therapy (CBT) intervention to reduce PPCV. Results of a pilot study of parents of premature infants (n = 41) demonstrate that the intervention can be delivered with high ratings of treatment fidelity and with a completion rate of 100% during the NICU admission, and 78% at 6 months post term. Ratings of parental satisfaction ranged between 4.9 and 5 out of 5 demonstrating high satisfaction with the intervention. Pilot feasibility and maternal satisfaction data are presented for a group of 22 intervention families, which suggest a CBT model for understanding VCS is feasible and deemed helpful by parents. This review is gauged to summarize risk of VCS development, diagnosis of VCS, and effective treatments for VCS through Cognitive Behavioral Therapy. We also present a paradigm shift in a therapeutic approach by introducing the PreVNT Trial. Given that VCS can interfere with the long-term outcomes of both infant and family, it is important to understand VCS and address its involvement in NICU and post NICU discharge care. Further research is needed in this area.

OBJECTIVES Determine sources of error in electronically extracted data from electronic health records. STUDY DESIGN Categorical and continuous variables related to early-onset neonatal hypoglycemia were preselected and electronically extracted from records of 100 randomly selected neonates within 3479 births with laboratory-proven early-onset hypoglycemia. Extraction language was written by an information technologist and data validated by blinded manual chart review. Kappa coefficient assessed categorical variables and percent validity continuous variables. RESULTS 8/23 (35%) categorical variables had acceptable Κappa (1-0.81); 5/23 (22%) had fair-slight agreement, Κappa

To examine the inter-rater reliability for the diagnosis of LSV on cranial ultrasound (cUS), determine the risk factors associated with LSV and its progression, and examine neurodevelopmental outcome. Prospective case–control study of neonates ≤32wks of gestation assessed for LSV by serial cUS (n = 1351) between 2012 and 2014 and their neurodevelopment at 18–36mon-corrected age compared to controls. Agreement for LSV on cUS improved from Κappa 0.4–0.7 after establishing definitive criteria and guidelines. BPD was the only variable associated with the occurrence and the progression of LSV. Cytomegalovirus (CMV) infection occurred in one neonate (1.5%). Neurodevelopmental outcome of neonates with LSV did not differ from controls. Establishment of well-defined stages of LSV improves the reliability of the diagnosis and allows identification of neonates with progression of LSV. Although LSV was associated with BPD, it was not associated with congenital CMV infection.

The lack of a valid and safe method for measuring length in critically ill preterm neonates has led to a primary focus on weight gain. Paucity of valid length measurements, precluding the accurate analysis of growth patterns. Quality improvement project among infants