Virtual Workspaces for Web-based Emergent Processes

Organizations operating in increasingly competitive and volatile environments are turning to flexible orga-nizational forms such as virtual teams and virtual organizations as solutions. Much of the work of such virtual organizational forms exhibits characteristics of emergence. While the extension of workflow technology to deal with evolving processes is current research, this paper asserts that it is inappropriate for emergent processes. As an alternative, a model of workspaces, together with an underlying model of cooperation, is introduced. This model has been implemented in the LiveNet prototype system, which is presented. LiveNet is a Web-based work-space system which provides a context for cooperation without imposing a rigid process structure. Workspaces are seen not as static structures, but as highly flexible and dynamic, evolving along with the collaboration carried out in them. As LiveNet can be used over the Internet, it is of particular value to geographically dispersed virtual teams

Evaluating the Utility of Diagnostic Workups for Biliary Atresia in Neonates with Cholestatic Jaundice Following Prolonged TPN

Introduction: Parenteral nutrition associated cholestasis (PNAC) develops in 40-60% of premature infants following TPN for 2-4+ weeks. The incidence of biliary atresia is low and there is a 60-day, post-term window for corrective surgery. There is limited data on both the natural history of PNAC in premature infants following prolonged TPN, as well as the utility of diagnostic tools investigating biliary atresia in these patients. Methods: A retrospective chart review using EMR data from the Intensive Care Nursey was performed with the following criteria: premature babies diagnosed with cholestasis, born at \u3c1500 grams, and received TPN for 14 days. Ultimately 61 babies met criteria and data was collected and pooled to produce descriptive statistics and graphs describing laboratory trends. Results: Median gestational age was 26 [IQR 25, 28] weeks, birth weight was 732 [650, 930] grams and 60% (36/60) were male. After being on TPN for a median of 51 [38, 73] days and developing cholestasis, 12/61 (19.7%) babies underwent hepatobiliary scintigraphy, three of which also underwent repeat scans, 29/61 (47.5%) received GI consults and 32/61 (52.5%) underwent abdominal ultrasounds. No babies were diagnosed with biliary atresia. Graphical depiction of laboratory trends demonstrates an initial spike in direct bilirubin after TPN cessation, followed by a gradual decline 3-4 weeks later. Discussion: Despite many diagnostic procedures and consults, PNAC was the only observed diagnosis at discharge for this cohort of babies. Based on the laboratory trends, delaying the investigation of elevated bilirubin until 3-4 weeks after ceasing TPN might prevent unnecessary diagnostics and improve resource allocation

Lung Rest During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure-Practice Variations and Outcomes.

OBJECTIVE: Describe practice variations in ventilator strategies used for lung rest during extracorporeal membrane oxygenation for respiratory failure in neonates, and assess the potential impact of various lung rest strategies on the duration of extracorporeal membrane oxygenation and the duration of mechanical ventilation after decannulation. DATA SOURCES: Retrospective cohort analysis from the Extracorporeal Life Support Organization registry database during the years 2008-2013. STUDY SELECTION: All extracorporeal membrane oxygenation runs for infants less than or equal to 30 days of life for pulmonary reasons were included. DATA EXTRACTION: Ventilator type and ventilator settings used for lung rest at 24 hours after extracorporeal membrane oxygenation initiation were obtained. DATA SYNTHESIS: A total of 3,040 cases met inclusion criteria. Conventional mechanical ventilation was used for lung rest in 88% of cases and high frequency ventilation was used in 12%. In the conventional mechanical ventilation group, 32% used positive end-expiratory pressure strategy of 4-6 cm H2O (low), 22% used 7-9 cm H2O (mid), and 43% used 10-12 cm H2O (high). High frequency ventilation was associated with an increased mean (SEM) hours of extracorporeal membrane oxygenation (150.2 [0.05] vs 125 [0.02]; p \u3c 0.001) and an increased mean (SEM) hours of mechanical ventilation after decannulation (135 [0.09] vs 100.2 [0.03]; p = 0.002), compared with conventional mechanical ventilation among survivors. Within the conventional mechanical ventilation group, use of higher positive end-expiratory pressure was associated with a decreased mean (SEM) hours of extracorporeal membrane oxygenation (high vs low: 136 [1.06] vs 156 [1.06], p = 0.001; mid vs low: 141 [1.06] vs 156 [1.06]; p = 0.04) but increased duration of mechanical ventilation after decannulation in the high positive end-expiratory pressure group compared with low positive end-expiratory pressure (p = 0.04) among survivors. CONCLUSIONS: Wide practice variation exists with regard to ventilator settings used for lung rest during neonatal respiratory extracorporeal membrane oxygenation. Use of high frequency ventilation when compared with conventional mechanical ventilation and use of low positive end-expiratory pressure strategy when compared with mid positive end-expiratory pressure and high positive end-expiratory pressure strategy is associated with longer duration of extracorporeal membrane oxygenation. Further research to provide evidence to drive optimization of pulmonary management during neonatal respiratory extracorporeal membrane oxygenation is warranted

Effects of Neonatal Abstinence Syndrome on Long-Term Growth Parameters

Introduction: Past studies have shown that babies with Neonatal Abstinence Syndrome (NAS) have lower weight, head circumference, and height at birth. This study aims to compare their growth at 9 and 18 months of age, and to compare growth parameter of NAS infants below 10th percentile to those above 10th percentile at birth. Methods: In this retrospective review, 260 infants admitted to Jefferson Neonatal Intensive Care Unit between 2006 and 2018 were included. The weight, height, and head circumference at birth, 9 months, and 18 months were collected and correlated by Pearson correlation. The growth parameters of infants below 10th percentile at birth were also compared with those above 10th percentile by appropriate statistical tests. Results: There was a significant but weak correlation between birth and 9 month weight, head circumference, and length (r=0.28, p \u3c 0.001; r=0.22, p = 0.001; and r=0.13, p = 0.048; respectively) which persisted at 18 months for weight and head circumference but not for length. There were significant differences in weight (p = 0.01), head circumference (p = 0.02), and length (p = 0.02) between infants below 10th percentile and those above 10th percentile at 9 months, but not at 18 months. Discussion: The results implicate that NAS infants who were small for gestational age at birth catch up to their counterparts in physical growth parameter. Further studies on longer term follow-up and underlying factors that allow for this growth could help design interventions that enhance their growth

Is NIPPV Superior to CPAP in Maintaining Targeted Oxygen Saturation Ranges in Preterm Infants on Moderate Non-Invasive Respiratory Support?

Background: Non-invasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP) are non-invasive respiratory supports commonly used in preterm infants. There is conflicting data on the superiority between these two modes of non-invasive respiratory support. The objective of this study was to determine if oxygen saturation is more within the target range on NIPPV compared to CPAP using the data from histograms. Methods: Retrospective analysis of premature neonates (\u3c 1500 grams, gestational age \u3c 30 weeks) admitted to the NICU for which oxygen saturation histogram data was available one day before and after the transition between NIPPV and CPAP. FiO2 at the time of data collection was greater than 21 percent. This histogram data, the percentage of time spent in certain SpO2 ranges, was compared before and after the de-escalation from NIPPV to CPAP or escalation from CPAP to NIPPV. FiO2 was additionally compared between the two modes of respiratory support. Results: A total of 26 infants were included. The median gestational age was 25.5 weeks and the median weight of the infants was 792 grams. Among the 26 infants, there were 34 episodes of transition between NIPPV and CPAP, 19 switches from NIPPV to CPAP, and 15 from CPAP to NIPPV. The percentage of time that oxygen saturation was within the target range (89-94 %) was not statistically significant between the two modes of respiratory support (CPAP 39.9% vs. NIPPV 43.9%, p=0.09) (Table 1). The percentage of time that oxygen saturation was between 86-88% was higher on NIPPV and the percentage of time that oxygen saturation was \u3e94% was higher on CPAP. There was a trend towards lower FiO2 on NIPPV compared to CPAP. When switched from NIPPV to CPAP, there was a higher percentage of time spent above the target range ( \u3e94%) while on CPAP (56% vs 49%, p=0.001), and below the target range (86-88%) while on NIPPV (5.0% vs 1.4%, p=0.02) (Table 3). When switched from CPAP to NIPPV, there was no difference in oxygen saturation ranges (Table 2). Conclusion: Target oxygen saturation ranges on histogram data were similar in premature infants when supported on CPAP and NIPPV. However, oxygen saturation below the target range was more frequent on NIPPV compared to CPAP. NIPPV is not superior to CPAP in maintaining oxygen saturation within the target range in premature infants on moderate non-invasive respiratory support. The potential risk of low oxygen saturation range while supported on NIPPV in preterm infants requires further research.https://jdc.jefferson.edu/pulmcritcareposters/1003/thumbnail.jp