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biIntroduction:/i/bTeleneonatology (TN) allows remote neonatologists to provide real-time audio-video telemedicine support to community hospitals when neonates require advanced resuscitation or critical care. Currently, there are no published economic evaluations of U.S. TN programs.biObjective:/i/bTo evaluate the cost of TN from the perspective of the health care system.biMethods:/i/bWe constructed a decision tree comparing TN to usual care for neonates born in hospitals without a neonatal intensive care unit (NICU) who require consultation. Our outcome of interest was total cost per patient, which included the incremental cost of a TN program, the cost of medical transport, and the cost of NICU or non-NICU hospitalization. We performed threshold sensitivity analyses where we varied each parameter to determine whether the base-case finding reverted.biResults:/i/bFor neonates requiring consultation after birth in a hospital without a NICU, TN was less costly ($16,878) than usual care ($28,047), representing a cost-savings of $11,168 per patient. Sensitivity analyses demonstrated that at least one of the following conditions would need to be met for TN to no longer be cost saving compared to usual care: transfer rate with usual carelt;12% (base-case = 82%), TN reducing the odds of transfer bylt;8% (base-case = 52%), or TN cost exceeding $12,989 per patient (base-case = $1,821 per patient).biConclusions:/i/bEconomic modeling from the health system perspective demonstrated that TN was cost saving compared to usual care for neonates requiring consultation following delivery in a non-NICU hospital. Understanding the cost savings associated with TN may influence organizational decisions regarding implementation, diffusion, and retention of these programs.

ImportanceThere was a shift in patient volume from in-person to video telemedicine visits during the COVID-19 pandemic.ObjectiveTo determine the concordance of provisional diagnoses established at a video telemedicine visit with diagnoses established at an in-person visit for patients presenting with a new clinical problem.Design, Setting, and ParticipantsThis is a diagnostic study of patients who underwent a video telemedicine consultation followed by an in-person outpatient visit for the same clinical problem in the same specialty within a 90-day window. The provisional diagnosis made during the video telemedicine visit was compared with the reference standard diagnosis by 2 blinded, independent medical reviewers. A multivariate logistic regression model was used to determine factors significantly related to diagnostic concordance. The study was conducted at a large academic integrated multispecialty health care institution (Mayo Clinic locations in Rochester, Minnesota; Scottsdale and Phoenix, Arizona; and Jacksonville, Florida; and Mayo Clinic Health System locations in Iowa, Wisconsin, and Minnesota) between March 24 and June 24, 2020. Participants included Mayo Clinic patients residing in the US without age restriction. Data analysis was performed from December 2020 to June 2021.ExposuresNew clinical problem assessed via video telemedicine visit to home using Zoom Care Anyplace integrated into Epic.Main Outcomes and MeasuresConcordance of provisional diagnoses established over video telemedicine visits compared against a reference standard diagnosis.ResultsThere were 2393 participants in the analysis. The median (IQR) age of patients was 53 (37-64) years; 1381 (57.7%) identified as female, and 1012 (42.3%) identified as male. Overall, the provisional diagnosis established over video telemedicine visit was concordant with the in-person reference standard diagnosis in 2080 of 2393 cases (86.9%; 95% CI, 85.6%-88.3%). Diagnostic concordance by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision chapter ranged from 64.7% (95% CI, 42.0%-87.4%) for diseases of the ear and mastoid process to 96.8% (95% CI, 94.7%-98.8%) for neoplasms. Diagnostic concordance by medical specialty ranged from 77.3% (95% CI, 64.9%-89.7%) for otorhinolaryngology to 96.0% (92.1%-99.8%) for psychiatry. Specialty care was found to be significantly more likely than primary care to result in video telemedicine diagnoses concordant with a subsequent in-person visit (odds ratio, 1.69; 95% CI, 1.24-2.30; P Conclusions and RelevanceThis diagnostic study of video telemedicine visits yielded a high degree of diagnostic concordance compared with in-person visits for most new clinical concerns. Some specific clinical circumstances over video telemedicine were associated with a lower diagnostic concordance, and these patients may benefit from timely in-person follow-up.

Background: The Mayo Clinic Center for Connected Care has an established organizational framework for telehealth care delivery. It provides patients, consumers, care teams, and referring providers ...

The use of telemedicine has increased and may enhance the care of children during medical transport. We aimed to evaluate the feasibility of synchronous telemedicine connectivity before interfacility transport of critically ill children by a pediatric transport team.We performed a prospective, observational feasibility study of the introduction of synchronous telemedicine into an established pediatric transport team from 2019 to 2020. The outcomes examined included connectivity, physician workload, transport team satisfaction, and patient care outcomes.Among 118 eligible transports, telemedicine was considered in 23 transports (19%), including 11 transports in which an attempt to connect was sought and 12 in which telemedicine activation was offered but not attempted. The median connection time was 2.9 minutes (interquartile range, 1.7-4.4 minutes), and clinical care was altered in 1 case. Connection failed in 2 cases (18.2%). In 50% of cases, concurrent medical control physician workload prevented activation. There were no perceived benefits in 41.7% of cases. Team members indicated the desire for future telemedicine use in only 54.6% of cases.We found low utilization of synchronous telemedicine in interfacility pediatric transport. The identified barriers included reliable connectivity, physician workload, and low perceived benefit. Lessons learned and future research suggestions are presented to mitigate these barriers.

We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals. Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models. The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries. Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable.· Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

ObjectiveTo evaluate whole-genome sequencing (WGS) as a molecular typing tool for MRSA outbreak investigation.DesignInvestigation of MRSA colonization/infection in a neonatal intensive care unit (NICU) over 3 years (2014–2017).SettingSingle-center level IV NICU.PatientsNICU infants and healthcare workers (HCWs).MethodsInfants were screened for MRSA using a swab of the anterior nares, axilla, and groin, initially by targeted (ring) screening, and later by universal weekly screening. Clinical cultures were collected as indicated. HCWs were screened once using swabs of the anterior nares. MRSA isolates were typed using WGS with core-genome multilocus sequence typing (cgMLST) analysis and by pulsed-field gel electrophoresis (PFGE). Colonized and infected infants and HCWs were decolonized. Control strategies included reinforcement of hand hygiene, use of contact precautions, cohorting, enhanced environmental cleaning, and remodeling of the NICU.ResultsWe identified 64 MRSA-positive infants: 53 (83%) by screening and 11 (17%) by clinical cultures. Of 85 screened HCWs, 5 (6%) were MRSA positive. WGS of MRSA isolates identified 2 large clusters (WGS groups 1 and 2), 1 small cluster (WGS group 3), and 8 unrelated isolates. PFGE failed to distinguish WGS group 2 and 3 isolates. WGS groups 1 and 2 were codistributed over time. HCW MRSA isolates were primarily in WGS group 1. New infant MRSA cases declined after implementation of the control interventions.ConclusionWe identified 2 contemporaneous MRSA outbreaks alongside sporadic cases in a NICU. WGS was used to determine strain relatedness at a higher resolution than PFGE and was useful in guiding efforts to control MRSA transmission.

Teleneonatology may improve the quality of high-risk newborn resuscitations performed by general providers in community settings. Variables that affect teleneonatology utilization have not been identified.The objective of our mixed-methods study was to understand the barriers and facilitators experienced by local care providers who receive teleneonatology services.In October 2015, an electronic survey was sent to 349 teleneonatology participants at 6 community hospitals to assess user satisfaction, technology usability and acceptability, and impact on patient care. From December 2015 to June 2016, 49 participants were involved in focus groups and individual interviews to better understand barriers and facilitators of teleneonatology implementation. Qualitative data were analyzed using a thematic approach.Survey response rate was 31.8% (N = 111). Of 93 survey respondents, 88 (94.6%) agreed that teleneonatology was needed at their hospitals, and of 52 participants, 50 (96.2%) believed that teleneonatology consults were helpful. We identified multiple facilitators and barriers to program implementation in education and training, process and work flow, communication, and technology.Local care teams believed that teleneonatology was valuable for connection to a remote neonatologist. Successful program implementation may be facilitated by communicating the value of teleneonatology, engaging local stakeholders in program training and education, maintaining supportive professional relationships, and designing simple, highly reliable clinical work flows.Teleneonatology is viewed as an innovative, valuable service by local care teams. The identified barriers and facilitators to program use should be considered when implementing a teleneonatology program.

Background: Early work has demonstrated the feasibility and acceptance of newborn resuscitation telemedicine programs (NRTPs). The technology requirements for providing this type of emergency telemedicine service are unclear. Introduction: We hypothesized that during NRTP consults, a wired telemedicine cart would provide a more reliable and higher-quality user experience than a consumer-grade wireless tablet. Materials and Methods: In this retrospective observational study, six spoke sites used consumer-grade wireless tablets during preintervention and wired coder/decoder (CODEC)-based telemedicine carts during postintervention. Both technologies used the same videoconferencing software. After the telemedicine consult, providers completed surveys assessing connection reliability, user satisfaction, and audio and video quality using a 1–5 Likert scale. Results: Preintervention, users completed 99 consults and 95 surveys. Postintervention, users completed 73 consults and 192 surveys. Successful connection on first attempt was significantly improved with the wired cart compared with the wireless tablet (82.7% vs. 69.5%, p = 0.01), and the percentage of consults complicated by an unplanned disconnection was reduced (6.4% vs. 14.7%, p = 0.02). User satisfaction and video and audio quality ratings were significantly higher for the wired cart. Discussion: The wired telemedicine cart increased connection reliability, which is important given the critical nature and long duration of NRTP consults. Audio-video quality was also improved, allowing for better visualization of the neonate and communication with the care team. Conclusions: Consumer-grade wireless tablets did not meet the program's technical requirements. Wired telemedicine carts improved reliability, user satisfaction, and audio-video quality. Wired carts may not fully meet NRTP requirements because of cart size and limited mobility.

Objective To introduce the prenatal regenerative medicine service at Mayo Clinic for fetal endoscopic tracheal occlusion (FETO) care for severe congenital diaphragmatic hernia (CDH). Patients and Methods Two cases of prenatal management of severe CDH with FETO between January and August 2017 are reported. Per protocol, FETO was offered for life-threatening severe CDH at between 26 and 29 weeks' gestation. Regenerative outcome end point was fetal lung growth. Gestational age at procedure and maternal and perinatal outcomes were additional monitored parameters. Results Diagnosis by ultrasonography of severe CDH was based on extremely reduced lung size (observed-to-expected lung area to head circumference ratio [o/e-LHR], eg, o/e-LHR of 20.3% for fetus 1 and 23.0% for fetus 2) along with greater than one-third of the liver herniated into the chest in both fetuses. Both patients underwent successful FETO at 28 weeks. At the time of intervention, no maternal or fetal complications were observed. Postintervention, fetal lung growth was observed in both fetuses, reaching an o/e-LHR of 62.7% at 36 weeks in fetus 1 and 52.4% at 32 weeks in fetus 2. The balloons were removed successfully at 35 weeks and 4 days by ultrasound-guided puncture in the first patient and at 32 weeks and 3 days by ex utero intrapartum therapy-to-airway procedure in the second patient. Postnatal management followed standard of care with patch CDH therapy. At discharge, one patient was breathing normally, whereas the other required minimal nasal cannula oxygen support. Conclusion The successful launch of the first fetoscopic therapy for CDH at Mayo Clinic reveals its feasibility and safety, with early signs of benefit documented by fetal lung growth and reversal of severe pulmonary hypoplasia. Trial Registration clinicaltrials.gov Identifier: G170062.

Background. The recent joint International Society for Pharmacoeconomics and Outcomes Research / Society for Medical Decision Making Modeling Good Research Practices Task Force emphasized the importance of conceptualizing and validating models. We report a new model of chronic obstructive pulmonary disease (COPD) (part of the Galaxy project) founded on a conceptual model, implemented using a novel linked-equation approach, and internally validated. Methods. An expert panel developed a conceptual model including causal relationships between disease attributes, progression, and final outcomes. Risk equations describing these relationships were estimated using data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study, with costs estimated from the TOwards a Revolution in COPD Health (TORCH) study. Implementation as a linked-equation model enabled direct estimation of health service costs and quality-adjusted life years (QALYs) for COPD patients over their lifetimes. Internal validation compared 3 years of predicted cohort experience with ECLIPSE results. Results. At 3 years, the Galaxy COPD model predictions of annual exacerbation rate and annual decline in forced expiratory volume in 1 second fell within the ECLIPSE data confidence limits, although 3-year overall survival was outside the observed confidence limits. Projections of the risk equations over time permitted extrapolation to patient lifetimes. Averaging the predicted cost/QALY outcomes for the different patients within the ECLIPSE cohort gives an estimated lifetime cost of £25,214 (undiscounted)/£20,318 (discounted) and lifetime QALYs of 6.45 (undiscounted/5.24 [discounted]) per ECLIPSE patient. Conclusions. A new form of model for COPD was conceptualized, implemented, and internally validated, based on a series of linked equations using epidemiological data (ECLIPSE) and cost data (TORCH). This Galaxy model predicts COPD outcomes from treatment effects on disease attributes such as lung function, exacerbations, symptoms, or exercise capacity; further external validation is required.

Objective To describe the Mayo Clinic experience with emergency video telemedicine consultations for high-risk newborn deliveries. Patients and Methods From March 26, 2013, through December 31, 2015, the Division of Neonatal Medicine offered newborn telemedicine consultations to 6 health system sites. A wireless tablet running secure video conferencing software was used by the local care teams. Descriptive data were collected on all consultations. After each telemedicine consult, a survey was sent to the neonatologist and referring provider to assess the technology, teamwork, and user satisfaction. Results During the study, neonatologists conducted 84 telemedicine consultations, and 64 surveys were completed. Prematurity was the most frequent indication for consultation (n=32), followed by respiratory distress (n=15) and need for advanced resuscitation (n=14). After the consult, nearly one-third of the infants were able to remain in the local hospital. User assessment of the technology revealed that audio and video quality were poor or unusable in 16 (25%) and 12 (18.8%) of cases, respectively. Providers failed to establish a video connection in 8 consults (9.5%). Despite technical issues, providers responded positively to multiple questions assessing teamwork (86.0% [n=37 of 43] to 100.0% [n=17 of 17] positive responses per question). In 93.3% (n=14 of 15) of surveyed cases, the local provider agreed that the telemedicine consult improved patient safety, quality of care, or both. Conclusion Telemedicine consultation for neonatal resuscitation improves patient access to neonatology expertise and prevents unnecessary transfers to a higher level of care. A highly reliable technology infrastructure that provides high-quality audio and video should be considered for any emergency telemedicine service.

Objective To assess our initial experience with prenatal restoration of hindbrain herniation following in utero repair of myelomeningocele (MMC). Patients and Methods Three consecutive patients with prenatally diagnosed MMC (between January 1, 2018 and September 30, 2018) were managed with open in utero surgery. As per institutional review board approval and following a protocol designed at the Mayo Clinic Maternal & Fetal Center, fetal intervention was offered between 19 0/7 and 25 6/7 weeks of gestation. Prenatal improvement of hindbrain herniation was the declared restorative end point. Obstetrical and perinatal outcomes were also assessed. Results Diagnosis of MMC was confirmed upon referral between 20 and 21 weeks' gestation by using fetal ultrasound and magnetic resonance imaging. In all cases reported here, the spinal defect was lumbosacral with evidence of hindbrain herniation. Open in utero MMC repair was performed between 24 and 25 weeks' gestation with no notable perioperative complications. Postprocedure fetal magnetic resonance imaging performed 6 weeks after in utero repair documented improvement of hindbrain herniation. Deliveries were at 37 weeks by cesarean section without complications. Most recent postnatal follow-ups were unremarkable at both 11 months (baby 1) and 3 months of age (baby 2), with mild ventriculomegaly. Antenatal and postnatal follow-up of baby 3 at 1 month of age was also unremarkable. Conclusion Our study highlights the prenatal restoration of hindbrain herniation following in utero MMC repair in all cases presented here as an example of a prenatal regenerative therapy program in our institution.

Objectives: Blood specimen hemolysis is a major cause of sample recollection in the neonatal intensive care unit. We aimed to reduce the hemolysis rate from 6.3% at baseline to less than 4% within the 9 months’ duration of the study. Methods: Intravenous infusion of lipid emulsion during sample collection, sample collection site, and blood sample transportation methods were investigated as possible contributors to hemolysis. Subsequently, two practice improvements were implemented: pausing lipid emulsion infusion prior to collection and slowing withdrawal rates through arterial catheters. Results: Samples were more likely to be hemolyzed if they were collected during lipid infusion and subsequently transported by pneumatic tube or collected through an arterial catheter. Retrospective analysis demonstrated a decreased number of tests cancelled due to specimen hemolysis (3.5%) after our interventions. Conclusions: We identified three variables contributing to hemolysis and instituted two clinical practice interventions to significantly reduce test cancellations due to hemolysis.

Objective The objective of this study was to determine whether packed red blood cell (pRBC) transfusions in extremely low birth weight (ELBW) infants were associated with acute respiratory decompensation (ARD). Study Design Retrospective chart review of ELBW infant pRBC transfusions analyzed for meeting ARD criteria during the 6 hours post-pRBC transfusion was compared with the pretransfusion baseline period. A control period subdivided into similar pre- and postintervals was also assessed for each infant. ARD was defined as ≥ 1 of the following: (1) ≥ 10% increase in fraction of inspired oxygen from highest baseline, (2) ≥ 2 cm H2O increase from highest baseline in mean airway pressure, or (3) escalation in mode of respiratory support. Results A total of 238 pRBC transfusions occurred in 36 ELBW infants during 2012. Complete data for both the transfusion and control time periods existed for 110 pRBC transfusions (25 infants) and were included for analysis. The frequency of ARD was 15.5 and 18.2% (odds ratio, 1.25; p = 0.70) in the control and transfusion time periods, respectively. Conclusion pRBC transfusions in ELBW neonates are not associated with statistically significant rates of ARD compared with nontransfusion control time periods.

Purpose: To describe a single center experience with emergency video telemedicine for newborn resuscitations and compare quality metrics for two telemedicine technologies. Methods: In this pre-post observational study, descriptive data was collected on all clinical video telemedicine consultations. During the pre-intervention phase, local care teams used wireless tablets with secure video conferencing software for telemedicine consultation. During the post-intervention phase, wired telemedicine carts that included a high-definition, pan/tilt/zoom camera and a noise-cancelling, full-duplex microphone/speaker set were utilized. After clinical and simulated consults, surveys were administered to the neonatologist and local care team to measure the reliability of connection, …

Objectives: To provide a national estimate of the incidence of hospitalizations due to osteoporotic fractures (OFs) in women; compare this with the incidence of myocardial infarction (MI), stroke, and breast cancer; and assess temporal trends in the incidence and length of hospitalizations. Patients and Methods: The study included all women 55 years and older at the time of admission, admitted to a hospital participating in the US Nationwide Inpatient Sample for an outcome of interest. We performed a retrospective analysis of hospitalizations for OFs (hip, forearm, spine, pelvis, distal femur, wrist, and humerus), MI, stroke, or breast cancer, using the US Nationwide Inpatient Sample, 2000-2011. Results: From 2000 to 2011, there were 4.9 million hospitalizations for OF, 2.9 million for MI, 3.0 million for stroke, and 0.7 million for breast cancer. Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. In comparison, MI, stroke, and breast cancer had age-adjusted incidence rates of 668, 687, and 151 admissions per 100,000 person-years, respectively. The annual total population facility-related hospital cost was highest for hospitalizations due to OFs ($5.1 billion), followed by MI ($4.3 billion), stroke ($3.0 billion), and breast cancer ($0.5 billion). Conclusion: These data provide evidence that in US women 55 years and older, the hospitalization burden of OFs and population facility-related hospital cost is greater than that of MI, stroke, or breast cancer. Prioritization of bone health and supporting programs such as fracture liaison services is needed to reduce this substantial burden.

Objective We hypothesized that telemedicine consults provided by neonatologists to local care teams (termed teleneonatology) would improve the quality of high-risk newborn resuscitations that occur in community hospitals. Methods This retrospective cohort study compared 47 newborns who received a teleneonatology consult during their resuscitation at a community hospital to 45 controls who did not. Controls were matched on gestational age, sex, admission diagnosis, and level of newborn care. A two-person expert panel blinded to the intervention reviewed demographic and resuscitation data for each patient and assigned a resuscitation quality rating using a 1–10 descriptive rating scale. Paired comparisons between groups were evaluated using the Wilcoxon signed rank test for continuous measures and the McNemar’s test for dichotomous measures. Results The median resuscitation quality rating was 7 for the teleneonatology group and 4 for the control group, with a median difference of 1 between matched pairs (P = .002). Neonates who received a teleneonatology consult were more likely to undergo measurement of temperature, glucose, and blood gases. When analyzing the 35 matched pairs that had a consult within one hour of birth, the positive impact of teleneonatology was greater (median rating 8 vs 4, median difference 2, P = .003). Subgroup analysis demonstrated teleneonatology significantly improved the resuscitation of preterm neonates (median rating 8 vs 4, median difference 1.5, P = .004) Conclusion Teleneonatology improves the quality of high-risk newborn resuscitations that occur in community hospitals and increases adherence to process metrics. Earlier teleneonatology consults appear to have greater positive impact.

Background. To develop statistical models predicting disease progression and outcomes in chronic obstructive pulmonary disease (COPD), using data from ECLIPSE, a large, observational study of current and former smokers with COPD. Methods. Based on a conceptual model of COPD disease progression and data from 2164 patients, associations were made between baseline characteristics, COPD disease progression attributes (exacerbations, lung function, exercise capacity, and symptoms), health-related quality of life (HRQoL), and survival. Linear and nonlinear functional forms of random intercept models were used to characterize these relationships. Endogeneity was addressed by time-lagging variables in the regression models. Results. At the 5% significance level, an exacerbation history in the year before baseline was associated with increased risk of future exacerbations (moderate: +125.8%; severe: +89.2%) and decline in lung function (forced expiratory volume in 1 second [FEV1]) (–94.20 mL per year). Each 1% increase in FEV1 % predicted was associated with decreased risk of exacerbations (moderate: –1.1%; severe: –3.0%) and increased 6-minute walk test distance (6MWD) (+1.5 m). Increases in baseline exercise capacity (6MWD, per meter) were associated with slightly increased risk of moderate exacerbations (+0.04%) and increased FEV1 (+0.62 mL). Symptoms (dyspnea, cough, and/or sputum) were associated with an increased risk of moderate exacerbations (+13.4% to +31.1%), and baseline dyspnea (modified Medical Research Council score ≥2 v. 1 (–112.3 mL). Conclusions. A series of linked statistical regression equations have been developed to express associations between indicators of COPD disease severity and HRQoL and survival. These can be used to represent disease progression, for example, in new economic models of COPD.

BACKGROUND AND OBJECTIVES: Infants in NICUs are at risk for underimmunization. Adherence to the routine immunization schedule recommended by the Advisory Committee for Immunization Practices minimizes the risk of contracting vaccine-preventable illnesses in this vulnerable population. From January 2015 to June 2017, only 56% (419 of 754) of the infants in our Mayo Clinic level IV NICU were fully up to date for recommended immunizations at the time of discharge or hospital unit transfer. We aimed to increase this rate to 80% within 6 months. METHODS: Using the quality improvement methodology of Define, Measure, Analyze, Improve, Control, we analyzed baseline data, including provider and nursing surveys using a fishbone diagram, the 5 Whys, and a Pareto chart. We identified 3 major root causes of the quality gap: lack of provider knowledge of the routine immunization schedule, failure of providers to order vaccines when due, and hesitancy of parents toward vaccination. Using plan-do-study-act cycles, 5 improvement interventions were implemented. These included an intranet resource for NICU providers on the routine immunization schedule, an Excel-based checklist to track when immunizations were due, and provider education on parental vaccine hesitancy and vaccine safety. RESULTS: During the 19-month improve and control phases of the project, the fully immunized rate at the time of NICU discharge or transfer rose from a baseline of 56% (419 of 754) to 93% (453 of 488), with a P value CONCLUSIONS: Our NICU significantly improved infant immunization rates with a small number of interventions. These interventions may be generalizable to other NICUs with low infant immunization rates.

Background and aims Little research has been done on tele‐intensive care unit (ICU) implementation across different types of ICUs, and there exist few studies that have used qualitative research methods to analyze the human and organizational factors influencing optimization of telemedicine for newborn resuscitation. The objective of this study was to understand health care professionals' acceptance, utilization, and integration of video telemedicine for newborn resuscitation (termed teleneonatology) in community hospital settings. Methods Focus group and individual interviews were conducted with 49 health care professionals at six affiliated health system hospitals. Data were gathered from physicians (n = 18), nurses (n = 30), and a nurse practitioner. Data were inductively analyzed using a thematic approach, and then constructs from normalization process theory (NPT) were deductively applied. NPT rendered a general framework to describe and assess how care teams perceive the implementation of teleneonatology and how they interact with this telemedicine service in their local setting. Results Local health care professionals accepted teleneonatology as an important, helpful service, yet its implementation was perceived as both valuable and a threat to professional traditions. Utilization may depend on perceived benefit, mutual understanding of the guidelines, and expectations of use, and other relational, human, contextual, and system factors. Participants in this study agreed on the need for collective work to successfully integrate teleneonatology into the local practice. Discussions NPT uncovered that successful implementation of a teleneonatology program may be facilitated by strong interpersonal relationships among care teams, continuous programmatic training and education, and communicating the clinical value of teleneonatology, including its opportunities and benefits.

Regardless of age, health care professionals have a professional and ethical obligation to provide safe and effective analgesia to patients undergoing painful procedures. Historically, newborns, particularly premature and sick infants, have been undertreated for pain. Intubation of the trachea and mechanical ventilation are ubiquitous painful procedures in the neonatal intensive care unit that are poorly assessed and treated. The authors review the use of sedation and analgesia to facilitate endotracheal tube placement and mechanical ventilation. Controversies regarding possible adverse neurodevelopmental outcomes after sedative and anesthetic exposure and in the failure to treat pain is also discussed.

BACKGROUND AND OBJECTIVE: Previous studies suggest that former late preterm infants are at increased risk for learning and behavioral problems compared with term infants. These studies have primarily used referred clinical samples of children followed only until early school age. Our objective was to determine the cumulative incidence of attention deficit/hyperactivity disorder (ADHD) and learning disabilities (LD) in former late preterm versus term infants in a population-based birth cohort. METHODS: Subjects included all children born 1976 to 1982 in Rochester, MN who remained in the community after 5 years. This study focused on the comparison of subjects in 2 subgroups, late preterm (34 to RESULTS: We found no statistically significant differences in the cumulative incidence of ADHD or LD between the late preterm (N = 256) versus term (N = 4419) groups: ADHD (cumulative incidence by age 19 years, 7.7% vs 7.2%; P = .84); reading LD (14.2% vs 13.1%; P = .57); written language LD (13.5% vs 15.7%; P = .36), and math LD (16.1% vs 15.5%; P = .89). CONCLUSIONS: These data from a population-based birth cohort indicate that former late preterm infants have similar rates of LD and ADHD as term infants.

To determine whether an electronic data surveillance system, or Data Sniffer (DS), could reduce the rate of hyperoxic episodes (HEs) among premature neonates being managed by a standardized respiratory treatment protocol (RTP).A total of 86 infants born at29 weeks of gestation were included in the study. The rates of HEs were compared among four epochs (E) as follows: E1: no RTP, no DS; E2:with RTP, no DS; E3: with RTP, with DS; E4: with RTP, no DS.After implementing the RTP in E2, the rate of HEs was 44% lower than that of E1. Activating the DS in E3 further reduced HEs by 26%, whereas its deactivation in E4 resulted in a rebound in HEs to baseline rates; P0.0001 for each comparison.The implementation of an electronic data monitoring system was associated with less frequent episodes of hyperoxia among premature neonates.

When a fetal anomaly is suspected, a multidisciplinary approach to diagnosis, counseling, pregnancy management, surveillance, delivery planning, and neonatal care is critical to creating a comprehensive management plan. This article provides a basic framework for integrating prenatal diagnostic and maternal-fetal care considerations, delivery planning, special resuscitation needs, and immediate and later neonatal care and evaluation into developing a thoughtful management plan for infants with prenatally diagnosed complex anomalies including congenital heart disease, intrathoracic masses, fetal airway obstruction, neural tube defects, abdominal wall defects, and skeletal dysplasia.

SummaryBackground Congenital diaphragmatic hernia (CDH) is a rare anomaly with high mortality and long-term comorbid conditions. Aims Our aim was to describe the presenting characteristics, treatment, and outcomes of consecutive patients with CDH treated at our institution. Methods We performed a retrospective cohort study and identified consecutive neonates treated for CDH from 2001 to 2015 at our institution. For all patients identified, we reviewed hospital and postdischarge data for neonatal, disease, and treatment characteristics. We determined hospital survival overall and also according to the presence of prenatal diagnosis, liver herniation into the chest (liver up), and the use of extracorporeal membrane oxygenation (ECMO) in addition to surgery. We evaluated postdischarge chronic conditions in patients with at least one year of follow-up. Results Thirty-eight neonates were admitted for treatment during the study period. In three who were in extremis, life support was withdrawn. The other 35 underwent surgical repair, of whom eight received ECMO. The overall survival was 79% (30/38). Survival for those who had surgical correction of CDH but did not need ECMO was 89% (24/27); it was 75% (6/8) for those who received ECMO and had surgery. Hospital survival was lower for liver-up vs liver-down CDH (61% [11/18] vs 95% [19/20]; odds ratio, 0.08; 95% CI, 0.01–0.77; P = 0.01). Among survivors, the median duration of hospitalization was 31 (interquartile range, 20–73) days. Major chronic pulmonary and gastrointestinal disorders, failure to thrive, and neurodevelopmental delays were the most noted comorbid conditions after discharge, and all were more prevalent in those who required ECMO. Conclusion The overall survival of neonates with CDH was 79%. Intrathoracic liver herniation was associated with more frequent use of ECMO and greater mortality. A substantial number of survivors, especially those who required ECMO, experienced chronic conditions after discharge.

Background Neonatal encephalopathy (NE) affects 2–4/1000 live births with outcomes ranging from negligible neurological deficits to severe neuromuscular dysfunction, cerebral palsy and death. Hypoxic ischemic encephalopathy (HIE) is the sub cohort of NE that appears to be driven by intrapartum events. Our objective was to identify antepartum and intrapartum factors associated with the development of neonatal HIE. Methods Hospital databases were searched using relevant diagnosis codes to identify infants with neonatal encephalopathy. Cases were infants with encephalopathy and evidence of intrapartum hypoxia. For each hypoxic ischemic encephalopathy case, four controls were randomly selected from all deliveries that occurred within 6 months of the case. Results Twenty-six cases met criteria for hypoxic ischemic encephalopathy between 2002 and 2014. In multivariate analysis, meconium-stained amniotic fluid (aOR 12.4, 95% CI 2.1–144.8, p = 0.002), prolonged second stage of labor (aOR 9.5, 95% CI 1.0–135.3, p = 0.042), and the occurrence of a sentinel or acute event (aOR 74.9, 95% CI 11.9-infinity, p

To describe the Mayo Clinic experience with emergency video telemedicine consultations for high-risk newborn deliveries.From March 26, 2013, through December 31, 2015, the Division of Neonatal Medicine offered newborn telemedicine consultations to 6 health system sites. A wireless tablet running secure video conferencing software was used by the local care teams. Descriptive data were collected on all consultations. After each telemedicine consult, a survey was sent to the neonatologist and referring provider to assess the technology, teamwork, and user satisfaction.During the study, neonatologists conducted 84 telemedicine consultations, and 64 surveys were completed. Prematurity was the most frequent indication for consultation (n=32), followed by respiratory distress (n=15) and need for advanced resuscitation (n=14). After the consult, nearly one-third of the infants were able to remain in the local hospital. User assessment of the technology revealed that audio and video quality were poor or unusable in 16 (25%) and 12 (18.8%) of cases, respectively. Providers failed to establish a video connection in 8 consults (9.5%). Despite technical issues, providers responded positively to multiple questions assessing teamwork (86.0% [n=37 of 43] to 100.0% [n=17 of 17] positive responses per question). In 93.3% (n=14 of 15) of surveyed cases, the local provider agreed that the telemedicine consult improved patient safety, quality of care, or both.Telemedicine consultation for neonatal resuscitation improves patient access to neonatology expertise and prevents unnecessary transfers to a higher level of care. A highly reliable technology infrastructure that provides high-quality audio and video should be considered for any emergency telemedicine service.

CONTEXT:The effectiveness of many interventions aimed at reducing the risk of retinopathy has not been well established.OBJECTIVE:To estimate the effectiveness of nutritional interventions, oxygen saturation targeting, blood transfusion management, and infection prevention on the incidence of retinopathy of prematurity (ROP).DATA SOURCES:A comprehensive search of several databases was conducted, including Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through March 2014.STUDY SELECTION:We included studies that evaluated nutritional interventions, management of supplemental oxygen, blood transfusions, or infection reduction and reported the incidence of ROP and mortality in neonates born at DATA EXTRACTION:We extracted patient characteristics, interventions, and risk of bias indicators. Outcomes of interest were any stage ROP, severe ROP or ROP requiring treatment, and mortality.RESULTS:We identified 67 studies enrolling 21 819 infants. Lower oxygen saturation targets reduced the risk of developing any stage ROP (relative risk [RR] 0.86, 95% confidence interval [CI], 0.77–0.97) and severe ROP or ROP requiring intervention (RR 0.58, 95% CI, 0.45–0.74) but increased mortality (RR 1.15, 95% CI, 1.04–1.29). Aggressive parenteral nutrition reduced the risk of any stage ROP but not severe ROP. Supplementation of vitamin A, E, or inositol and breast milk feeding were beneficial but only in observational studies. Use of transfusion guidelines, erythropoietin, and antifungal agents were not beneficial.LIMITATIONS:Results of observational studies were not replicated in randomized trials. Interventions were heterogeneous across studies.CONCLUSIONS:At the present time, there are no safe interventions supported with high quality evidence to prevent severe ROP.

A 1-day-old male infant is transferred to the neonatal intensive care unit with a large congenital skin defect of the inferior chest and abdomen extending in a butterfly distribution to the flanks (Figure 1). Figure 1. Well-demarcated butterfly-shaped lesion affecting skin, muscle, and fascia which spares the umbilicus. Photograph taken less than one day after birth. ### Prenatal and Birth Histories Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. ### Physical Examination

Background When developed in the 1990s, the Neurobiologic Risk Score (NBRS) and Neurodevelopmental Risk Exam (NRE) correlated well with developmental outcomes in premature infants. Given recent advances in neonatology, we assessed their present ability to predict cognitive outcome, alone and combined with socio-economic factors. Methods One hundred and twenty-nine neonates

This review discusses the use of extracorporeal membrane oxygenation (ECMO) for the treatment of respiratory failure in neonates. After briefly reviewing the early history of neonatal ECMO, the authors describe the respiratory diagnoses most often treated with ECMO and the manner in which affected neonates are deemed to have “failed” conventional therapies and thus require ECMO. After reviewing the most common indications for ECMO, factors that influence the timing of conversion to extracorporeal life support, as well as criteria that may exclude patients from receiving ECMO therapy, are described. At the conclusion of this article, the authors discuss the long-term outcomes of neonates whose respiratory disease was treated with ECMO and the costs associated with that care.

We sought to determine the current practices of neonatologists in their management of extremely low-birth-weight (< 1000 g) infants. We directly mailed an anonymous survey to the medical directors of 809 neonatal intensive care units in the United States. More than one-third of those surveyed responded, with a substantial majority from intensive care (level III) nurseries or extracorporeal membrane oxygenation centers. Academic centers and private practice environments were both well represented. Some traditional practices have changed, such as beginning resuscitation with 40% rather than 100% oxygen. Many practices vary based on whether neonates are cared for in private versus academic centers, including initial resuscitation method, type of ventilation used, use of intraventricular hemorrhage prophylaxis, and routine antibiotic therapy. Parenteral nutrition composition and the use of inhaled nitric oxide differ based on the responding center's participation in clinical trials. The number of years in practice as a neonatologist does not affect practice decisions. Among all our findings, the prevalence of one potentially harmful practice, the continued use of dexamethasone for corticosteroid therapy, was particularly noteworthy. In conclusion, the strength of evidence does not always predict whether practices are adopted or abandoned. Further research is necessary to clarify the optimal management for this high-risk patient population.

Large dural arteriovenous malformations (DAVMs) accompanied by cardiac failure usually carry a poor prognosis with a high risk of morbidity and death. The authors report on the case of a male neonate with a massive DAVM who presented at birth with macrocephaly and high-output cardiac failure. The child initially underwent treatment with surgical clipping of the large main feeding artery. Hydrocephalus, thought to be due to venous hypertension, developed when the boy was 8 months old. The condition resolved after interventional embolization treatment. The patient did not require placement of a ventriculoperitoneal shunt. At 21 months of age, the child had near normal development without any focal neurological deficits.

Advances in the understanding of neonatal pain have created interest in the use of medications during commonly performed procedures in the neonatal intensive care unit. A number of small studies have examined the role of sedatives, narcotics, miscellaneous anesthetics, and neuromuscular blockers in providing a more comfortable experience for the patient during nonemergent tracheal intubation. However, the most effective combination and doses of these medications is currently unknown. This review discusses the findings of selected studies that have been used to improve the intubating experience of patient and clinician.

A male infant was born at 26 6/7 weeks’ gestation to a 38-year-old woman whose pregnancy was complicated by premature rupture of membranes at 20 weeks’ gestation and placental abruption. The infant's birthweight was 910 g and Apgar scores were 5 and 7 at 1 and 5 minutes, respectively. He developed feeding intolerance and experienced four episodes of medically managed suspected necrotizing enterocolitis. He required parenteral nutrition (PN) for a total of 71 days and received full enteral feedings throughout the remainder of his hospitalization without evidence of acholic stools. On postnatal day 42, he developed jaundice, but the remainder of his physical examination findings were normal. Laboratory values at that time included a total bilirubin of 3.3 mg/dL (56.4 mcmol/L) and direct bilirubin of 2.6 mg/dL (44.5 mcmol/L) . The jaundice continued to progress, and on postnatal day 72, total bilirubin measured 9.5 mg/dL (162.5 mcmol/L) and direct bilirubin measured 6.4 mg/dL (109.5 mcmol/L). Abdominal ultrasonography revealed a liver and gallbladder of normal size and echotexture. Doppler flow evaluation demonstrated patency of the hepatic veins and inferior vena cava. The common bile duct was identified and measured 1 mm in diameter. Ursodeoxycholic acid (UDCA) (20 mg/kg per day) was started. The laboratory studies were negative for coagulopathy and glucose lability. Mild elevation of alanine aminotransferase (43 to 108 U/L) and elevated gamma-glutamyl transferase (250 to 256 U/L) were noted. Assessments for cystic fibrosis, alpha-1-antitrypsin deficiency, neonatal iron storage disease, and bile acid synthesis disorders returned negative results. A HIDA scan performed on postnatal day 74 revealed no obvious flow into the intestine, and phenobarbital (5 mg/kg per day) was started . Despite full enteral nutrition and treatment with UDCA and phenobarbital, the direct bilirubin continued to increase to 12.1 mg/dL (206.9 mcmol/L) on postnatal day 97. A repeat HIDA …

Objective Hemolytic disease of the newborn (HDN) most commonly occurs in neonates whose mothers carry nonpassively acquired antibodies directed against red blood cell (RBC) antigens. Because affected neonates may develop severe hyperbilirubinemia, early identification of at-risk neonates is critically important. We hypothesized that use of the direct antibody test (DAT) would be of high predictive value in identifying those neonates most likely to meet treatment criteria for hyperbilirubinemia. Study Design We performed a retrospective chart review of all mother–infant pairs in which RBC antibodies were detected on routine prenatal screening during the current pregnancy (2011–2013). We then compared DAT results of neonates who eventually met the treatment criteria for hyperbilirubinemia with those who did not. Main Results Fifty-sixty neonates were born to mothers with clinically significant antibodies. The sensitivity and specificity of a positive DAT result for meeting the treatment criteria were 87.5 and 93.3%, respectively. The positive and negative predictive values were 77.8 and 96.6%, respectively. Conclusion The result of a DAT, obtained in neonates of mothers with clinically relevant alloantibodies, is a specific marker with good positive predictive value for identifying those who are most likely to meet the treatment criteria for hyperbilirubinemia.

After completing this article, readers should be able to: 1. Describe the outcomes of assisted reproductive technologies (ART) for singleton, twin, and other multiple births. 2. Describe the role of fertility in adverse outcomes seen with ART births. 3. Review the association of birth defects with ART. 4. Delineate the association of disease of genomic imprinting with ART. 5. Describe the relationship between ART and the subsequent incidence of neurodevelopmental sequelae. In the 1977 ruling “Carey v. Population Services International,” the United States Supreme Court ruled that the decision to bear children is constitutionally protected. (1) Significant interest already had been shown in the development and improvements of in vitro fertilization (IVF) for infertile couples. The first human pregnancy and human birth using IVF were reported by Steptoe and Edwards in the United Kingdom. (2) Their work resulted in the first baby born via reproductive technologies, Louise Brown, born on July 25, 1978, at Oldham General Hospital in Oldham, United Kingdom. (3) She was born via a planned cesarean section, and her birthweight was 2.61 kg. The first successful viable IVF in the United States was performed by Jones and Seager-Jones in 1981 in Norfolk, Virginia. (4) Assisted reproductive technologies (ART) have seen a recent surge in popularity. The Centers for Disease Control and Prevention (CDC) reported that 122,872 cycles of ART were initiated in 2003, resulting in the delivery of 48,756 neonates, (5) accounting for approximately 1% of all neonates delivered in the United States. The percentage is higher in many countries, including Denmark, where it is estimated that 5% of all deliveries are with the assistance of ART. (6) Couples pursue ART for myriad reasons, including tubal transport factors, ovulatory dysfunction, uterine factors, endometriosis, male- and female-specific factors, and when a cause of infertility is unknown. (5) It would be very …