The NICU tracheostomy team: multidisciplinary collaboration for improvement in survival of complex patients.

OBJECTIVE: Evaluate feasibility and impact of "Tracheostomy Team" on survival and length of stay (LOS) at a level IV NICU. METHODS: Plan-do-study-act cycles targeted five Global Tracheostomy Collaborative "key drivers". From January 2017 to December 2022 multidisciplinary, bimonthly bedside rounds were conducted. RESULTS: After 3 cycles, in-hospital survival among 39 patients with tracheostomy improved and sustained from 67% to 100% (baseline 18/27; 66.7%; QI 35/39, 89.7%; p = 0.03). Median LOS (days [IQR]) did not significantly differ between baseline and QI (237 [57-308] vs. 217 [130-311]; p = 0.9). Among patients with BPD, median LOS was higher after QI interventions (baseline 248 [222-308] vs. QI 332.5 [283.5-392]; p = .02). Special cause variation resulted from peak increase in LOS during the COVID19 pandemic (2021). Tracheitis/pneumonia was treated significantly more frequently in QI BPD patients. CONCLUSION: Multidisciplinary approach is feasible, resulting in improved survival without a sustained increase in LOS. Future QI efforts should address post-operative infectious complications.

Short-term exposure to tricyclic antidepressants delays righting time in marine and freshwater snails with evidence for low-dose stimulation of righting speed by imipramine.

Active pharmaceutical ingredients such as tricyclic antidepressants (TCAs) are contaminants of emerging concern which are commonly detected in wastewater effluent and which can disrupt the behavior of non-target organisms. In aquatic snails, the righting response is a critical behavior that has been shown to be inhibited by exposure to SSRI-type antidepressants. We exposed marine and freshwater snails to three tricyclic antidepressants (clomipramine, amitriptyline, and imipramine) for 1 h and measured righting response time. In the marine mud snail (Ilyanassa obsoleta), all three TCAs significantly increased righting time at concentrations as low as 156 µg/L. Similarly, in the freshwater snail Leptoxis carinata, all three TCAs increased righting time at concentrations as low as 263 µg/L. However, exposure to imipramine from 15.8 to 316 µg/L resulted in significantly faster righting time. Such low-dose stimulation and high-dose inhibition are characteristics of a hormetic response. We discuss the possible physiological mechanism of action of TCAs and other antidepressants on snail behavior, and the occurrence of non-monotonic, hormetic dose responses to human pharmaceuticals in the aquatic environment.

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia.

BACKGROUND: Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data. METHODS: Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used. RESULTS: Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of $24/patient in the PED and $180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs. CONCLUSIONS: Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.