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Bighorn sheep (Ovis canadensis) across North America commonly experience population-limiting epizootics of respiratory disease. Although many cases of bighorn sheep pneumonia are polymicrobial, Mycoplasma ovipneumoniae is most frequently associated with all-age mortality events followed by years of low recruitment. Chronic carriage of M. ovipneumoniae by adult females serves as a source of exposure of naïve juveniles; relatively few ewes may be responsible for maintenance of infection within a herd. Test-and-remove strategies focused on removal of adult females with evidence of persistent or intermittent shedding (hereafter chronic carriers) may reduce prevalence and mitigate mortality. Postmortem confirmation of pneumonia in chronic carriers has been inadequately reported and the pathology has not been thoroughly characterized, limiting our understanding of important processes shaping the epidemiology of pneumonia in bighorn sheep. Here we document postmortem findings and characterize the lesions of seven ewes removed from a declining bighorn sheep population in Wyoming, USA, following at least two antemortem detections of M. ovipneumoniae within a 14-mo period. We confirmed that 6/7 (85.7%) had variable degrees of chronic pneumonia. Mycoplasma ovipneumoniae was detected in the lung of 4/7 (57.1%) animals postmortem. Four (57.1%) had paranasal sinus masses, all of which were classified as inflammatory, hyperplastic lesions. Pasteurella multocida was detected in all seven (100%) animals, while Trueperella pyogenes was detected in 5/7 (71.4%). Our findings indicate that not all chronic carriers have pneumonia, nor do all have detectable M. ovipneumoniae in the lung. Further, paranasal sinus masses are a common but inconsistent finding, and whether sinus lesions predispose to persistence or result from chronic carriage remains unclear. Our findings indicate that disease is variable in chronic M. ovipneumoniae carriers, underscoring the need for further efforts to characterize pathologic processes and underlying mechanisms in this system to inform management. [ABSTRACT FROM AUTHOR]

Functional analysis of one elementary student with attention deficit hyperactivity disorder indicated high levels of target behavior in both demand and attention conditions. False positives in the demand condition were revealed by within-session data analysis; modified functional analysis yielded reduced target behavior in demand and increases in the attention condition. Reversals confirmed modified analysis. Intervention based on these results achieved reductions in target behavior. (Contains references.) (Author/PB)

OBJECTIVE. The purpose of this work was to investigate whether using a muscle relaxant would improve intubation conditions in infants, thereby decreasing the incidence and duration of hypoxia and time and number of attempts needed to successfully complete the intubation procedure. PATIENTS/METHODS. This was a prospective, randomized, controlled, 2-center trial. Infants requiring nonemergent intubation were randomly assigned to receive atropine and fentanyl or atropine, fentanyl, and mivacurium before intubation. Incidence and duration of hypoxia were determined at oxygen saturation thresholds of [less than or equal to] 85%, [less than or equal to] 75%, [less than or equal to] 60%, and [less than or equal to] 40%. Videotape was reviewed to determine the time and number of intubation attempts and duration of action of mivacurium. RESULTS. Analysis of 41 infants showed that incidence of oxygen saturation [less than or equal to] 60% of any duration was significantly less in the mivacurium group (55% vs 24%). The incidence of saturation level of any duration [less than or equal to] 85%, 75%, and 40%; cumulative time [greater than or equal to] 30 seconds; and time below the thresholds were not significantly different. Total procedure time (472 vs 144 seconds) and total laryngoscope time (148 vs 61 seconds) were shorter in the mivacurium group. Successful intubation was achieved in [less than or equal to] 2 attempts significantly more often in the mivacurium group (35% vs 71%). CONCLUSIONS. Premedication with atropine, fentanyl, and mivacurium compared with atropine and fentanyl without a muscle relaxant decreases the time and number of attempts needed to successfully intubate while significantly reducing the incidence of severe desaturation. Premedication including a short-acting muscle relaxant should be considered for all nonemergent intubations in the NICU. Key Words intubation, premedication, atropine, fentanyl, mivacurium, muscle relaxant, hypoxia, infant, neonate Abbreviations ETT--endotracheal tube BP--blood pressure ICP--intracranial pressure HR--heart rate Sa[O.sub.2]--arterial oxygen saturation NNP--neonatal nurse practitioner FI[O.sub.2]--fraction of inspired oxygen SBP--systolic blood pressure, RECOGNITION AND MANAGEMENT of pain are important aspects of neonatal intensive care. In 2000, the American Academy of Pediatrics and the Canadian Paediatric Society published a consensus statement on the [...]

OBJECTIVES. Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool. METHODS. A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events. RESULTS. Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients CONCLUSIONS. Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events. Key Words trigger, adverse event, harm, NICU, patient safety Abbreviations AE--adverse event ADE--adverse drug event CHCA--Child Health Corporation of America IRB--institutional review board PPV--positive predictive value ECMO--extracorporeal membrane oxygenation, IN THE REPORT To Err is Human, (1) the Institute of Medicine concluded that between 44 000 and 98 000 lives are lost per year in US hospitals as a [...]

Objectives. Medical errors cause significant morbidity and mortality in hospitalized patients. Specialty-based, voluntary reporting of medical errors by health care providers is an important strategy that may enhance patient safety. We developed a voluntary, anonymous, Internet-based reporting system for medical errors in neonatal intensive care, evaluated its feasibility, and identified errors that affect high-risk neonates and their families. Methods. Health professionals (n = 739) from 54 hospitals in the Vermont Oxford Network received access to a secure Internet site for anonymous reporting of errors, near-miss errors, and adverse events. Reports used free-text entry in phase 1 (17 months) and a structured form in phase 2 (10 months). The number and types of reported events and factors that contributed to the events were measured. Results. Of 1230 reports--522 in phase 1 (17 months) and 708 in phase 2 (10 months)--the most frequent event categories were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). The most frequent contributory factors were failure to follow policy or protocol (47%), inattention (27%), communications problem (22%), error in charting or documentation (13%), distraction (12%), inexperience (10%), labeling error (10%), and poor teamwork (9%). In 24 reports, family members assisted in discovery, contributed to the cause, or themselves were victims of the error. Serious patient harm was reported in 2% and minor harm in 25% of phase 2 events. Conclusions. Specialty-based, voluntary, anonymous Internet reporting by health care professionals identified a broad range of medical errors in neonatal intensive care and promoted multidisciplinary collaborative learning. Similar specialty-based systems have the potential to enhance patient safety in a variety of clinical settings. Pediatrics 2004;113:1609-1618; patient safety, medical error, adverse events, medication error, iatrogenic, error reporting, quality improvement, multidisciplinary teams, neonate neonatal intensive care, Internet., ABBREVIATIONS. JCAHO, Joint Commission for Accreditation of Healthcare Organizations; NICQ, Neonatal Intensive Care Quality; TP, internet protocol; NICU, neonatal intensive care unit; FMEA, failure mode and effects analysis. In its [...]

Objective. Extremely low birth weight infants have a high risk of developing nosocomial bacterial sepsis (NBS). Immature fragile skin may represent an inadequate protective barrier to bacteria colonizing the skin. We conducted a randomized, multicenter trial to determine whether prophylactic application of an emollient ointment would result in a lower incidence of death and/or NBS in the first 28 days of life, compared with routine skin care. Methods. Infants of birth weight 501 to 1000 g and gestational age [less than or equal to] 30 weeks were assigned randomly to receive generalized application of ointment twice a day through day 14 (prophylactic group [P]) or local application of ointment to the site of injury (routine skin care [R]). The study was conducted at 53 neonatal intensive care units that were members of the Vermont Oxford Network. Results. Included in the analysis were 1191 infants (P: 602; R: 589). No difference was found in the combined primary outcome of NBS or death (33.6% P vs 30.3% R; relative risk [RR]: 1.10; 95% confidence interval [CI]: 0.89, 1.27). The incidence of death was no different between the groups (10.8% P vs 12.1% R; RR: 0.87; 95% CI: 0.59, 1.25). More infants in the prophylactic group had NBS (25.8% P vs 20.4% R; RR: 1.26; 95% CI: 1.02, 1.54), predominantly in the lower birth weight infants (501-750 g) and for infections caused by coagulase-negative staphylococci. Infants in the prophylactic group had better skin condition on days 1 to 14 of life and less skin injury on days 15 to 28 of life. There was no difference between groups in other complications of prematurity. Conclusions. Prophylactic application of ointment did not lead to a difference in death and/or NBS in the first 28 days of life. There may be an increase in the risk of NBS associated with this practice. Pediatrics 2004;113: 1195-1203; infant, premature, clinical trial randomized controlled trial, multicenter trial skin care, ointments, emollients, nosocomial sepsis. ABBREVIATIONS. NBS, nosocomial bacterial sepsis; ELBW, extremely low birth weight; RR, relative risk; ARR, adjusted relative risk; CI, confidence interval; CSF, cerebrospinal fluid., Nosocomial bacterial sepsis (NBS) is a frequent and serious complication of the care of premature infants. Extremely low birth weight (ELBW) infants with birth weights of The increased susceptibility of [...]