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Due to the changing complex healthcare environment, educational innovation is essential to meet the needs of current and future neonatal-perinatal medicine (NPM) leaders. Greater clinical demands, decreased academic funding, and expanded graduate medical education program requirements have negatively impacted time for teaching and educational scholarship potentially limiting innovation in the field. By focusing on adult learning principles, embracing technology, and promoting collaboration, today's educators are preparing the next generation of neonatologists. Current innovations include regionalizing simulation boot camps, leveraging virtual learning to increase accessibility, developing niche training opportunities, and incorporating population health principles within existing quality initiatives. Areas in need of additional innovation include faculty and fellow development for teaching skills, expansion of educational networks, and dissemination and financial support of educational scholarship. These efforts and future innovations will require medical institutions and national NPM organizations to further invest in the medical educator as part of their missions.

OBJECTIVEDespite longstanding and recurrent calls for effective implicit bias (IB) education in health professions education as one mechanism to reduce ongoing racism and health disparities, evidence-based IB curricula for neonatal-perinatal medicine (NPM) are limited. We aim to determine the key IB curricular elements for teaching NPM fellows, advanced practice providers, and attending physicians. STUDY DESIGNA modified Delphi study was performed with content experts in IB and health disparities who had educational relationships to those working and training in the neonatal intensive care unit. RESULTThree Delphi rounds were conducted. Experts reached consensus on a variety of items for inclusion in an IB curriculum, including educational goals, learning objectives, teaching strategies, and educator principles.CONCLUSIONEssential IB curricular components for the field of neonatal medicine were defined using rigorous consensus building methodology.

Background A vital element of the Next Accreditation System is measuring and reporting educational Milestones. Little is known about changes in Milestones levels during the transition from residency to fellowship training. Objective Evaluate the Accreditation Council for Graduate Medical Education (ACGME) Milestones' ability to provide a linear trajectory of professional development from general pediatrics residency to neonatal-perinatal medicine (NPM) fellowship training. Methods We identified 11 subcompetencies that were the same for general pediatrics residency and NPM fellowship. We then extracted the last residency Milestone level and the first fellowship Milestone level for each subcompetency from the ACGME's Accreditation Data System on 89 subjects who started fellowship training between 2014 and 2018 at 6 NPM fellowship programs. Mixed-effects models were used to examine the intra-individual changes in Milestone scores between residency and fellowship after adjusting for the effects of the individual programs. Results A total of 1905 subcompetency Milestone levels were analyzed. The average first fellowship Milestone levels were significantly lower than the last residency Milestone levels (residency, mean 3.99 [SD = 0.48] vs fellowship 2.51 [SD = 0.56]; P < .001). Milestone levels decreased by an average of -1.49 (SD = 0.65) from the last residency to the first fellowship evaluation. Significant differences in Milestone levels were seen in both context-dependent subcompetencies (patient care and medical knowledge) and context-independent subcompetencies (professionalism). Conclusions Contrary to providing a linear trajectory of professional development, we found that Milestone levels were reset when trainees transitioned from general pediatrics residency to NPM fellowship.

In the Canadian Arctic, the availability of sustainable drinking water supplies is threatened by pressures such as increasing populations, climate change, and the remote geographic nature of the communities. The objective of this study was to conduct a screening level vulnerability assessment of municipal drinking water supplies in the Canadian territory of Nunavut with consideration for climate change, population growth, and infrastructure changes. A hydrological analysis of primary drinking water supply watersheds was performed to evaluate the relative vulnerability level in 24 Nunavut communities. We used a water balance model to predict annual water yield from each watershed using historical and projected future climate data. Approximately 25% of the study communities were projected to experience high vulnerability to water shortages by 2070, defined as using greater than 40% of available water from their source watershed on an annual basis. A medium level of vulnerability (using 20% – 40% of annual available water) was determined for 8% of the study communities and a moderate level for 12% (using 10% – 20% of annual available water). A low vulnerability level to 2070 (using less than 10% of annual available water) was determined for 55% of the communities. The vulnerability level was primarily influenced by source watershed size. The results of this study could be used as a component of a proactive strategy to help address water security issues in Nunavut.

The management of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS) is complex. Significant variability in both practice and prevalence of ECLS use exists among centers, given the lack of evidence to guide management decisions. The purpose of this report is to review existing evidence and develop management recommendations for CDH patients treated with ECLS. This article was developed by the Extracorporeal Life Support Organization CDH interest group in cooperation with members of the CDH Study Group and the Children's Hospitals Neonatal Consortium.

Johnston L, Hiscock A, Holmes B, Bermarija T, Scott R, Sinclair A, Jamieson R. 2020. Trophic triage: a tiered eutrophication vulnerability screening tool for lakes in sparsely monitored regions. La...

Wastewater-based surveillance methods have been implemented in several countries as a tool for monitoring SARS-CoV-2 at a community scale. A variety of methods have been used for concentrating, extracting, and detecting the virus, with no clear consensus on the most effective approach. In this note, we report preliminary findings from a study that is tracking SARS-CoV-2 in wastewater in Halifax, Nova Scotia, with a specific focus on the use of four reverse transcriptase quantitative PCR (RT-qPCR) assays for detecting the virus in wastewater. We were able to detect the virus in wastewater samples during the initial rise of cases in the Halifax region in early November 2020. Levels of the targeted SARS-CoV-2 gene fragments increased and fell in response to reported cases of COVID-19. The CDC N1 and E RT-qPCR assays demonstrated greater relative sensitivity than the CDC N2 and N3 assays for detection of SARS-CoV-2 in raw sewage samples.

Introduction: Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed. Methods: Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference). Results: Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11–0.30) for residents and 0.80 (95% CI: 0.51–1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation. Conclusion: Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.

ObjectiveDescribe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes.DesignRetrospective analysis of TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS).SettingThirteen academic NICUs.PatientsInfants undergoing TI between October 2014 and December 2017.Main outcome measuresAssociation of family presence with TI processes and outcomes including first attempt success (primary outcome), success within two attempts, adverse TI-associated events (TIAEs) and severe oxygen desaturation ≥20% from baseline.ResultsOf the 2570 TIs, 242 (9.4%) had family presence, which varied by site (median 3.6%, range 0%–33%; pConclusionFamily are present in less than 10% of TIs, with variation across NICUs. Even after controlling for important patient, provider and site factors, there were no significant associations between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

Objective This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. Study Design This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. Results Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30–60 vs. 0–15 minutes, p Conclusion Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.

Cognitive appraisal of stress can influence performance. Increased awareness could facilitate titration to optimal stress levels. This study’s primary aim was to investigate whether physiologic variables change with increasingly stressful simulations. Secondary aims include effect of stress on procedural competency and whether individuals recognize their experienced stress. This was a single-center, mixed-method, simulation-based study. Participants completed three scenarios requiring resuscitation under increasingly stressful conditions. Wearable biometric devices recorded physiologic parameters. Subjects completed surveys assessing knowledge and perceived stress. Intubation success or failure was noted. Heart rate variability (HRV) analysis was used as a proxy for stress. Twelve participants completed the study. Survey analysis revealed progressive amplification of endorsement of affective states associated with stress. Median low frequency (LF)/high frequency (HF) ratio from scenario 1 (median = 2.29, IQR = 1.97, 3.91) was significantly lower than scenario 2 (median = 4.7, IQR = 2.32, 8.35, p = 0.04) and scenario 3 (median = 4.63, IQR = 2.2, 7.43, p = 0.04). Changes in HRV were noted during all scenarios irrespective of subjective self-assessment of stress. Procedural proficiency suffered during more stressful scenarios. This study demonstrates alterations in subjective assessment and objective physiologic data in simulations with increasing stress. HRV is useful as a proxy for stress response and does not always correlate with perception.

To describe the current educational status of percutaneously inserted central catheter (PICC) insertion/ maintenance training for neonatal–perinatal medicine (NPM) fellows in the United States. A cross-sectional 34-question survey was electronically distributed to NPM fellowship training program directors (PDs) in the United States. The response rate was 81.8% (81/99 PD). Most PDs (68.5%) reported that their neonatal intensive care unit has a PICC team. Fellows were PICC team members in 72%. Only 52% of programs offer formal training in PICC placement to fellows; 61.5% of these utilize a standardized curriculum. Dedicated PICC team existence was negatively associated with formal training for PICC insertion and maintenance for fellows (42.0% with PICC team vs. 73.91% without, p = 0.01). Wide variation exists in fellow’s exposure, education, and competency assessment in PICC-related activities nationally. Development of a standardized curriculum would be beneficial.

Wastewater stabilization ponds (WSPs) are commonly used to treat municipal wastewater in the Canadian Arctic. Bacterial community structure and functionality remain mostly uncharacterized for arctic WSPs, yet are presumed important for treatment outcomes during the 3-month summer treatment season with open water in the WSPs. The objective of this study was to investigate treatment performance and related temporal and spatial changes in the structure and putative function of bacterial communities during treatment of municipal wastewater in the WSPs of Pond Inlet and Clyde River, Nunavut over two consecutive summer treatment seasons. Influent raw wastewater contained a high organic load and large bacterial communities (~9 log 16S rRNA copies/mL) belonging mainly to Proteobacteria. Although designed to be facultative ponds, both WSPs remained anaerobic with neutral pH values (7.5–7.8) throughout the summer treatment season. Water quality data showed that nutrients [measured as carbonaceous biological oxygen demand (CBOD5)], total suspended solids, and total ammonia nitrogen were progressively reduced during treatment in the ponds as the summer progressed. The pond bacterial population size and species richness depended on the pond temperature (2–18°C), with 8.5 log 16S rRNA copies/mL and the largest alpha diversities (Shannon-Wiener index of 4-4.5) observed mid-season (late July). While the phylogenetic beta diversity in raw wastewater from the two locations remained similar, pond bacterial communities underwent significant (p < 0.05) changes to dominance of Comamonadaceae, Geobacteracea, and Porphyromonadaceae. Multivariate distance based redundancy analysis and predicted gene functionalities in the microbiota agreed with water quality results that microbial removal of nutrients (e.g., CBOD5) peaked in the middle of the summer coinciding with the treatment period with the highest pond temperatures. Information from this study will be useful for further development of models to predict biological treatment outcomes, which could be used to size and assess the feasibility of WSPs in extreme climates. Higher pond temperatures resulted in optimal biological processes and nutrient removal in the middle of the summer. While it is challenging to control environmental factors in a passive wastewater treatment system there are some design considerations that could be used to optimize temperature regimes, such as the depth of the pond.

OBJECTIVES To characterize neonatal-perinatal medicine fellows’ progression toward neonatal intubation procedural competence during fellowship training. METHODS Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows’ intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success. RESULTS There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07–1.14). CONCLUSIONS The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees’ progression toward intubation competence is warranted.

Understanding the interactions between ground freeze-thaw, groundwater flow, and solute transport is imperative for evaluating the fate of contaminants in permafrost regions. However, predicting solute migration in permafrost-affected groundwater systems is challenging due to the inherent interactions and coupling between subsurface mass and energy transport processes. To this end, we developed a numerical model that considers coupled groundwater flow, subsurface heat transfer, and solute transport, including water-ice phase change, solute-dependent porewater freezing, and temperature-dependent solute reaction rates. As an illustrative example, we present simulations to investigate the potential for contamination from a municipal wastewater lagoon in the Canadian sub-arctic. Two-dimensional groundwater models assuming varying permafrost conditions were developed to evaluate possible contaminant migration scenarios associated with groundwater flow from the lagoon to a river, including the transport of conservative, degradable, and sorbing solutes. Model results reveal important transport mechanisms controlling the behavior of aqueous contaminants in permafrost landscapes as well as the hydrogeologic factors affecting reactive transport in cold regions. Seasonal freeze-thaw episodically restricts connectivity of transport pathways, which attenuates both transport and reaction rates. However, elevated solute concentrations can depress the freezing temperature of porewater and produce thaw-induced solute transport. Both thermally driven and solute-enhanced thaw can decrease ice content in permafrost, which can have significant implications for solute migration. Therefore, thermo-hydrogeologic process controlling reactive transport in cold-region groundwater systems must be considered when quantitatively assessing the impact of changing environmental conditions on contaminant hydrogeology.

Background: Characteristics of neonatal tracheal intubations (TI) may vary between the neonatal intensive care unit (NICU) and delivery room (DR). The impact of the setting on TI outcomes is not well characterized. Objective: The aim of this study was to define variation in neonatal TI practice between settings, and identify the association between setting and TI success and safety outcomes. Design: This was a retrospective cohort study of TIs in the National Emergency Airway Registry for Neonates from October 2014 to September 2017. The setting (NICU vs. DR) was the exposure of interest. The outcomes were first attempt success, course success, success within 4 attempts, adverse TI-associated events, severe desaturation, and bradycardia. We compared TI characteristics and outcomes between settings in univariable analysis. Factors significant in univariable analysis (p < 0.1) were included in a logistic regression model, with adjustment for clustering by center, to identify the independent impact of the setting on TI outcomes. Results: There were 3,145 TI encounters (2279 NICU, 866 DR) in 9 centers. Almost all baseline characteristics significantly varied between settings. First attempt success rates were 48% (NICU) and 46% (DR). In multivariable analysis, the setting was not associated with first attempt success. DR was associated with a higher adjusted OR (aOR) of success within 4 attempts (1.48, 95% CI 1.06–2.08) and a lower aOR for bradycardia (0.43, 95% CI 0.26–0.71). Conclusion: Significant differences in patient, provider, and practice characteristics exist between NICU and DR TIs. There is substantial room for improvement in first attempt success rates. These results suggest interventions to improve safety and success need to be targeted to the distinct setting.

Background Simulation is widely used in graduate medical education. A prior survey showed that 80% of Neonatal-Perinatal Medicine (NPM) fellowship programs in the U.S. use simulation. There are multiple ways to provide simulation-based education. One such method is through intensive simulation-based education sessions held at the beginning of a training program, common called 'boot camps'. The aim of this study was to describe the use of simulation-based boot camps in NPM fellowship programs. Methods Survey study of Accreditation Council for Graduate Medical Education (ACGME) accredited NPM fellowships in the U.S. Results Fifty-nine of 98 programs (60%) responded. Thirty six (61%) participated in 1st year fellow boot camps, which focused on procedural skills and newborn resuscitation. Nearly half of programs participated in regional boot camps. Most boot camps were one or two days long. Eleven programs (19%) held 2nd or 3rd year fellow boot camps, which focused on advanced resuscitation and communication. Barriers included lack of faculty protected time (57%), funding (39%), and lack of faculty experience (31%). Conclusions A majority of ACGME accredited NPM fellowships participate in 1st year fellows' boot camps. Many participate in regional boot camps. A few programs have 2nd or 3rd year fellow boot camps. Lack of time, funding, and faculty experience were common barriers.

The coronavirus disease 2019 (COVID-19) pandemic has disrupted most in-person simulation training, including established simulation-based medical bootcamps. These sessions are important for the preparation of new trainees to think critically about common clinical scenarios, practice technical skills, and optimize leadership, teamwork, and communication. Having the opportunity to hone these skills in a safe environment is instrumental for the development of trainees' confidence and professional identity formation, and may contribute to patient safety. When the annual New England/Mid-Atlantic regional first-year neonatology fellows' bootcamp was jeopardized by COVID restrictions, we implemented a novel approach to adapt the existing in-person format and curriculum for large-scale hybrid delivery. The resultant two-day session was well-received by both participants and facilitators. Important lessons from this experience, including adaptions to the curriculum, schedule, simulation interface and hybrid platform, are relevant to educators seeking to conduct large-scale virtual simulation-based educational sessions.

Background: Active, learner-centric educational methods in graduate medical education are infrequently used despite evidence suggesting they are more effective for adult learners. The Organization of Neonatal-Perinatal Medicine (NPM) Training Program Directors developed a National Neonatology Curriculum to teach neonatal physiology incorporating andragogic principles. Using American Board of Pediatrics content specifications, NPM faculty developed peer-reviewed online videos and discussion guides for flipped classroom (FC) sessions. Objective: To determine NPM fellow (learner) preferences for FC vs. TD modalities in a large, randomized controlled trial. We hypothesized that fellows would prefer FC compared to TD. Methods: NPM fellowships were prospectively cluster randomized to FC or TD …

The management of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS) is complex. Significant variability in both practice and prevalence of ECLS use exists among centers, given the lack of evidence to guide management decisions. The purpose of this report is to review existing evidence and develop management recommendations for CDH patients treated with ECLS. This article was developed by the Extracorporeal Life Support Organization CDH interest group in cooperation with members of the CDH Study Group and the Children's Hospitals Neonatal Consortium.

There is a natural application of simulation for the training of extracorporeal membrane oxygenation (ECMO) providers based upon key concepts in adult learning theory (ALT), including behaviorism, constructivism, social cognitive, and experiential learning. Application of simulation in many high-risk fields, including healthcare, has resulted in significant benefits to enhancing safety. ECMO simulation provides an optimal environment to focus on critical decision-making under pressure, practice of procedural/technical skills, and optimization of communication strategies across the interprofessional team. However, simulation is just one part of an ECMO educational curriculum, and educators should ensure that this instructional method is employed in a manner that most appropriately aligns with the goals and objectives. Additionally, assessment of ECMO providers remains a topic of significant interest, and it is likely that simulation will be utilized as part of a formal system for credentialing ECMO providers in the future.

Introduction Although care for neonates with cardiac disease is frequently provided by neonatologists and pediatric cardiologists, training in the multidisciplinary management of neonatal cardiac emergencies is not often included in fellowship training. We created a multidisciplinary simulation curriculum to address the skills needed for neonatal cardiac care. Methods Neonatology and pediatric cardiology fellows participated in 1-hour simulations on 3 different days. They managed a neonate with: (1) cyanosis, (2) cardiogenic shock, and (3) an unstable arrhythmia. Using both remote consultation and bedside evaluation, the participants diagnosed and jointly established a management plan for the infant. During the debrief, facilitators reviewed the clinical decisions and multidisciplinary management skills of the participants. Participants completed pre- and postparticipation surveys to evaluate the curriculum's effect on their confidence in the management of neonatal cardiac disease. Results Thirty-three paired survey responses from 20 participants (11 neonatology and 9 pediatric cardiology) reported a mean overall satisfaction score of 4.6 (SD = 0.7) based on a 5-point Likert scale. Postparticipation confidence scores improved significantly in: (1) the recognition of the signs of congenital heart disease (pre = 4.1, post = 4.5, p = .01), (2) differentiation of cardiac cyanosis from noncardiac cyanosis (pre = 3.9, post = 4.2, p = .05), and (3) confidence in discussing cardiac concerns with consultants (pre = 3.3, post = 4.1, p = .02). Discussion This multidisciplinary simulation improved fellows’ confidence in the management of neonates with cardiac disease and provided an opportunity to practice team work, remote consultation, and cross-disciplinary communication.

Introduction: Intubations are frequently performed procedures in neonatal intensive care units (NICU) and delivery rooms (DR). Unsuccessful first attempts are common as are tracheal intubation-associated events (TIAEs) and severe desaturations. Stylets are often used during intubation, but their association with intubation outcomes is unclear. Objective: To compare intubation success, rate of relevant TIAEs, and severe desaturations in neonates intubated with and without stylets. Methods: Tracheal intubations of neonates in the NICU or DR from 16 centers between October 2014 and December 2018, performed by neonatology or pediatric providers, were collected from the NEAR4NEOs international registry. Primary oral intubations with a laryngoscope were included in the analysis. First-attempt success, the occurrence of relevant TIAEs, and severe oxygen desaturation (≥20% saturation drop from baseline) were compared between intubations performed with versus without a stylet. Logistic regression with generalized estimate equations was used to control for covariates and clustering by sites. Results: Out of 5,292 primary oral intubations, 3,877 (73%) utilized stylets. Stylet use varied considerably across the centers with a range between 0.5 and 100%. Stylet use was not associated with first-attempt intubation success, esophageal intubation, mainstem intubation, or severe desaturations after controlling for confounders. Patient size was associated with these outcomes and much more predictive of success. Conclusions: Stylet use during neonatal intubation was not associated with higher first-attempt intubation success, fewer relevant TIAEs, or less severe desaturations. These data suggest that stylets can be used based on individual preference, but stylet use may not be associated with better intubation outcomes.

The National Hydrometric Program, operated by the Water Survey of Canada, is the primary source of surface water quantity data in Canada. The network is cost-shared between the federal and provincial governments, and decisions relating to station placement are made according to both federal and provincial interests. Nova Scotia is a small maritime province in Atlantic Canada that is roughly one third the size of England and Wales and has a diverse climate and geology. The Nova Scotia hydrometric monitoring network currently consists of just 31 stations. The overall objective of this study was to determine how well the current network captures the level of hydrologic variability expected in the province using a regional catchment classification scheme. To accomplish this, we developed a combined inductive-deductive catchment classification system and applied it to the province’s active monitoring network and ungauged major watersheds. Initially, hydrologic signatures were used to quantify the catchment function of 47 long-term gauged catchments and to cluster similarly behaving catchments. We identified five generalized flow classes and then attempted to replicate this classification using a deductive-based decision tree framework with physiographic and meteorological explanatory variables. The validated decision tree was used to classify the active hydrometric network and 250+ major watersheds in the province. The network was assessed to determine how well it covered the expected hydrologic variability in the major watersheds across the province. The decision tree proved to be a useful tool for understanding the current network’s coverage and could also be easily applied by practitioners to identify appropriate donor catchments for ungauged watersheds.

Objectives:The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization.Design:Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication.Setting:In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education.Patients:None.Interventions:None.Measurements and Main Results:The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development.Conclusions:Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.

A well-organized educational curriculum for the training of both novice and experienced ECMO providers is critical for the continued function of an institutional ECMO program. ELSO provides guidance for the education for ECMO specialists, physicians and staff, which incorporates "traditional" instructor-centered educational methods, such as didactic lectures and technical skill training. Novel research suggests utilization of strategies that align with principles of adult learning to promote active learner involvement and reflection on how the material can be applied to understand existing and new constructs may be more effective. Some examples include the "flipped classroom," e-learning, simulation, and interprofessional education. These methodologies have been shown to improve active participation, which can be related to improvements in understanding and long-term retention. A novel framework for ECMO training is considered. Challenges in assessment and credentialing are also discussed.

Field crop growers in the United States have adopted prophylactic pest management strategies to control sporadic crop pests that are spatially and temporally difficult to predict. While evidence shows these preventative management practices, specifically pesticidal seed treatments, can be important in regions with predictable pest pressures, employing them ubiquitously in field crops across the northeastern U.S. can have variable returns on productivity. Further, prophylactics may also limit the potential of integrated pest management (IPM). A three-year field experiment (2017–2019) was conducted in a maize-soybean cropping system to compare the influence of a preventative pest management practice and a scouting-based IPM practice on biological control organisms. Aboveground predator densities were measured via pitfall trapping and predation temporal dynamics were assessed using a standard sentinel-bait assay at two time points per year. Belowground biological control potential was determined using a sentinel-bait bioassay to quantify the abundance of soil-borne entomopathogenic fungi (EPF). The variable responses of beneficial communities to pesticide inputs were strongly influenced by season and time of application, underscoring the importance of applying pesticides only when necessary. Compared with no pesticide use, pesticidal seed treatments and foliar sprays together in a maize-soybean production system suppressed total predator activity-density, spider activity-density, predation, and infection potential of soil-borne entomopathogenic fungi in one out of three years of the field study. In the third year, the activity-density of spiders increased across all fields in preventative plots that included seed treatments only. Overall, the use of pesticides did not improve crop yield in either maize or soybean. These findings highlight that the use of a prophylactic pesticide program may not always be necessary for maximum crop productivity and that this management approach can occasionally have unintended negative consequences on above- and belowground soil biota and the ecosystem services they provide.

Purpose: The learning environment encompasses the diverse physical locations, contexts, instructional methods, and cultures where learning occurs. Effective learning environments require preparation, promote collaboration, improve critical thinking, and increase learner engagement and knowledge retention. The Organization of Neonatal-Perinatal Medicine Training Program Directors (ONTPD) National Neonatology Curriculum (NNC) Randomized Controlled Trial (RCT) explored the impact of instructional methods on perceptions of the learning …

Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.

Objective This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations. Study Design TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated. Result In this study, 208 of 2,009 TIs (10%) had high stress levels (score Conclusion High team stress levels during TI were more frequently reported among TIs with adverse events.

BACKGROUND AND OBJECTIVES: Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. METHODS: We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation–associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression. RESULTS: We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28–0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25–0.57). CONCLUSIONS: We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.