An occurrence of apnea, bradycardia, and desaturation events resulting in a delay of discharge in late preterm and full term infants

In a 5-year retrospective study, we identified a population of late preterm and full term infants with apnea, bradycardia, and oxygen desaturation (ABD) events as the last discharge-delaying diagnosis

Global heat uptake by inland waters

Heat uptake is a key variable for understanding the Earth system response to greenhouse gas forcing. Despite the importance of this heat budget, heat uptake by inland waters has so far not been quantified. Here we use a unique combination of global-scale lake models, global hydrological models and Earth system models to quantify global heat uptake by natural lakes, reservoirs, and rivers. The total net heat uptake by inland waters amounts to 2.6 ± 3.2 ×1020 J over the period 1900–2020, corresponding to 3.6% of the energy stored on land. The overall uptake is dominated by natural lakes (111.7%), followed by reservoir warming (2.3%). Rivers contribute negatively (-14%) due to a decreasing water volume. The thermal energy of water stored in artificial reservoirs exceeds inland water heat uptake by a factor ∼10.4. This first quantification underlines that the heat uptake by inland waters is relatively small, but non-negligible

FcγRIII Is Protective against Pseudomonas aeruginosa Pneumonia

Defenses against bacterial infections involve activation of multiple systems of innate immunity, including complement, Toll-like receptors, and defensins. Reactions to chronic infections bring adaptive immune mechanisms into play as well, with the introduction of modulatory interactions between the two. In humans with chronic lung infections, the severity of inflammation and disease correlate with elevated levels of pathogen-specific immune complexes and complement activation. In mice with genetic deficiency in C5, or targeted deletion of the C5a receptor, Pseudomonas lung infections reveal a role for the C5a anaphylatoxin in disease severity. Deficient animals exhibit significantly reduced survival and clearance of infecting bacteria, simultaneous with greatly increased pulmonary influx of inflammatory cells. Among the actions of C5a on inflammatory cells mediated through the C5a receptor is a shift in the relative expression of Fcγ receptors to increase FcγRIII relative to FcγRII. This shift may significantly impact defenses against chronic infection, reflecting the cellular activation profiles of these IgG receptors. We addressed the role of FcγRIII in defense against Pseudomonas lung infection, and found that, like C5aR-deficient mice, animals with targeted deletion of FcγRIII are more susceptible to mortality upon infection and exhibit reduced clearance of the pathogen. Pseudomonas infection was associated with an increase in the FcγRIII/FcγRII ratio in wild-type mice, and the data support its role as an additional mechanism of host defense against bacterial infection

Pediatric Obstructive Sleep Apnea in High-Risk Populations: Clinical Implications

Certain common medical conditions are associated with a higher risk of pediatric obstructive sleep apnea (OSA). A lower threshold for screening is therefore indicated for such patient cohorts. In this article, we briefly discuss the high prevalence of OSA in children born prematurely, and in those with Down syndrome, craniofacial disorders, and neuromuscular disorders. Primary care providers should have an increased index of suspicion for OSA in these children, considering the neurocognitive disability that occurs in these high-risk groups when OSA is left untreated. [Pediatr Ann. 2017;46(9):e336-e339.]

Pediatric Obstructive Sleep Apnea and Asthma: Clinical Implications

Obstructive sleep apnea (OSA) and asthma are common conditions in children with preventable long-term consequences. There is significant overlap in symptomatology and pathophysiology for pediatric OSA and asthma. Recent evidence supports clear associations between the two diseases; however, causality has not been demonstrated. Regardless, it is important to recognize the overlap and evaluate for the other condition when one is present. For example, in patients with severe OSA, clinical evaluation for asthma should be considered, including history for typical asthma symptoms and spirometry. For patients with severe or poorly controlled asthma, OSA should be considered as a complicating condition. Clinical history for OSA as well as pediatric sleep questionnaires may be helpful tools in evaluation of the child with severe asthma. To decrease long-term consequences from asthma and OSA in children, clinicians should consider the relationship between these two diseases. [Pediatr Ann. 2017;46(9):e332-e335.]

Diagnostic Evaluation and Home Monitor Use in Late Preterm to Term Infants With Apnea, Bradycardia, and Desaturations

Apnea, bradycardia, and oxygen desaturation events are a common in neonatal intensive care units, with relevant literature to date largely focusing on very low birth weight and extremely low birth weight infants. We conducted a retrospective review of infants born at ≥34 weeks gestational age at 2 tertiary neonatal intensive care units in Boston, MA, between January 2009 and December 2013. Our objectives included (1) describing the diagnostic evaluations performed in late preterm to term infants with discharge-delaying apnea, bradycardia, or oxygen desaturation events and (2) identifying variables associated with home monitor use. Of the 741 eligible infants identified, diagnostic evaluations were variable and infrequent with blood culture, blood glucose, and head ultrasound performed most commonly. The likelihood of home monitor use was greater in infants with either a prolonged inpatient stay or greater gestational age at birth

Economics of Home Monitoring for Apnea in Late Preterm Infants

BACKGROUND: Apnea of prematurity affects a small proportion but large absolute number of late preterm infants, with out-patient management variably utilized despite relative clinical equipoise and potential for improved cost-effectiveness. METHODS: Over a 5-y period, from 2009 to 2013, infants born at \u3e /=34 weeks gestational age at a level IIIB academic center in Boston, Massachusetts, with discharge-delaying apnea, bradycardia, and desaturation (ABD) events were identified. In-patient costs for discharge-delaying ABD events were compared with hypothetical out-patient management. Out-patient costs took into account 4-10 d of in-patient observation for ABD events before caffeine initiation, 3-5 d of additional in-patient observation before discharge, daily caffeine until 43 weeks corrected gestational age, home pulse oximetry monitoring until 44 weeks corrected gestational age, and consideration of variable readmission rates ranging from 0 to 10%. RESULTS: A total of 425 late preterm and term infants were included in our analysis. Utilization of hypothetical out-patient management resulted in cost savings per eligible patient ranging from $2,422 to$62, dependent upon variable periods of in-patient observation. Sensitivity analysis demonstrated few instances of decreased relative cost-effectiveness. CONCLUSIONS: Out-patient management of discharge-delaying ABD events in a late preterm and term population was a cost-effective alternative to prolonged in-patient observation

Lack of Progression of Intraventricular Hemorrhage in Premature Infants: Implications for Head Ultrasound Screening

Very preterm infants are at risk for germinal matrix hemorrhage- intraventricular hemorrhage (GH-IVH). Severe GH-IVH may cause death or severe neurodevelopmental disability while mild GH-IVH is considered a static, non-progressive disease. This retrospective study aimed to determine if infants with no GH-IVH or mild GH-IVH on initial screening head ultrasound (HUS) advanced to severe GH-IVH. A total of 353 eligible infants with birth gestational age \u3c /=32 0/7 weeks who received a HUS during hospitalization were identified. Of the 343 (97%) infants who had mild GH-IVH (grade II or less) on initial screening, only 4 (1.2%) progressed to severe (grade III or IV). Each of these infants required mechanical ventilation for at least 40 days. Therefore, premature infants who have no GH-IVH or mild GH-IVH on initial routine screening HUS without other risk factors may not require follow-up HUSs. Infants with prolonged mechanical ventilation may require further screening despite reassuring initial HUS findings

Transcutaneous carbon dioxide pattern and trend over time in preterm infants

BACKGROUND: Chronic lung disease remains a burden for extremely preterm infants. The changes in ventilation over time and optimal ventilatory management remains unknown. Newer, non-invasive technologies provide insight into these patterns. METHODS: This single-center prospective cohort study enrolled infants \u3c /=32 0/7 weeks. We obtained epochs of transcutaneous carbon dioxide (TcCO2) measurements twice each week to describe the pattern of hypercarbia throughout their hospitalization. RESULTS: Patterns of hypercarbia varied based on birth gestational age and post-menstrual age (PMA) (p = 0.03), regardless of respiratory support. Infants receiving the most respiratory support had values 16-21 mmHg higher than those on room air (p \u3c 0.001). Infants born at the youngest gestational ages had the greatest total change but the rate of change was slower (p = 0.049) compared to infants born at later gestational ages. All infants had TcCO2 values stabilize by 31-33 weeks PMA, when values were not significantly different compared to discharge. No rebound was observed when infants weaned off invasive support. CONCLUSIONS: Hypercarbia improves as infants approached 31-33 weeks PMA. Hypercarbia was the highest in the most immature infants and improved with age and growth despite weaning respiratory support. IMPACT: This study describes the evolution of hypercarbia as very preterm infants grow and develop. The pattern of ventilation is significantly different depending on the gestational age at birth and post-menstrual age. Average transcutaneous carbon dioxide (TCO2) decreased over time as infants became more mature despite weaning respiratory support. This improvement was most significant in infants born at the lowest gestational ages

Approaches to Addressing Social Determinants of Health in the NICU: a Mixed Methods Study

Objective: Examine current approaches to addressing social determinants of health (SDOH) in the NICU and perceived appropriateness of a standardized screening and referral process. Study design: We performed a mixed methods study in two Massachusetts safety-net NICUs. We examined rates that unmet basic needs were assessed and identified among 601 families. We conducted focus groups with NICU staff to understand current methods to assess unmet basic needs and perceived appropriateness of a standardized SDOH screening and referral process. Result: Except employment (89%), other unmet basic needs were infrequently assessed (housing 38%, food/hunger 7%, childcare 3%, transportation 3%, utilities 0.2%). Staff believed: (1) processes to assess SDOH were not standardized and inconsistently performed/documented; (2) addressing SDOH was important; and (3) using a standardized screening and referral process would be feasible. Conclusions: Current NICU assessment of SDOH is limited and use of a standardized screening and referral process could be useful