Community violence and pregnancy health behaviors and outcomes.

OBJECTIVES: Community violence is associated with health-compromising behaviors (HCBs) and adverse general health and pregnancy outcomes. It is unknown whether these effects persist after adjusting for health behaviors. METHODS: Retrospective cohort study of 36,637 pregnancies, 2005-2009, using birth certificate/hospital discharge databases. Community violence rate = (nonaccidental injuries/total injuries) × 100%. ZIP codes were categorized into levels (CVL) by quartiles (lowest, 1, to highest, 4). Outcomes included HCBs (tobacco, alcohol, or drugs), fetal death, preterm birth, and infant small-for-gestational-age (SGA). Covariates included HCBs and maternal characteristics. RESULTS: The CVL median (interquartile range) was 5.5% (3.8%-8.8%). As CVL increased, rates of HCBs (8% vs 13% vs 14% vs 16%), fetal death (4 vs 5 vs 6 vs 8/1000 pregnancies), preterm birth (8% vs 9% vs 11% vs 13%), and infant SGA (8% vs 10% vs 13% vs 16%) increased. The odds of preterm birth (CVL1 = 1.00 [reference] vs CVL2 = 1.00 [0.88-1.14] vs CVL3 = 1.10 [0.96-1.26] vs CVL4 = 1.25 [1.09-1.42]) and infant SGA (CVL2 = 1.03 [0.93-1.17] vs CVL3 = 1.15 [1.01-1.30] vs CVL4 = 1.21 [1.07-1.38]) increased, after controlling for HCB. CONCLUSIONS: CVL is associated with fetal death, preterm birth, and infant SGA, independent of HCB. These findings may support the role of violence-reduction programs in improving pregnancy health behaviors and outcomes.

Perceptions of a strategy to prevent and relieve care provider distress in the neonatal intensive care unit.

BACKGROUND: A Midwestern neonatal intensive care unit (NICU) employs a multidisciplinary conference, the Comprehensive Care Round (CCR), to facilitate communication and consensus building and thereby prevent or address moral distress within the health care team. METHODS: A cross-sectional survey, 3 years after implementation of CCR, to evaluate health care providers' (HCP) perceptions of comfort with expressing distress, support from team members in care situations that evoke moral distress, barriers to communication, and attainment of CCR objectives. RESULTS: Of 370 HCP, 116 (31%) participated in the survey (42% nurses, 37% allied health, and 21% medical); 51% had previously attended CCR. CCR attendance was higher among HCP aged >35 years, those who cared for CCR patients, and nonnurses. Neonatologist were more likely than others (44% versus 4%, p <0.01) to report that referred cases were not overdue for discussion and that families appreciated the attention their child received from CCR. Of note, HCP who were comfortable with expressing distress also felt supported by team members (R = 0.5, p <0.001). CONCLUSION: CCR, developed to prevent or address moral distress, occurs later than most NICU HCP consider appropriate and appears to better serve HCP who are already comfortable with discussing moral distress. Helping HCP become comfortable with crucial conversations should support meaningful participation and contribution to multidisciplinary conferences.

Airway injury resulting from repeated endotracheal intubation: Possible prevention strategies.

OBJECTIVE: To characterize physical and inflammatory injury that may result from repeated intubation, independent of positive-pressure ventilation; and to determine whether corticosteroids can attenuate injury and or inflammation that may result from repeated intubation. DESIGN: A 4-hr animal protocol. SETTING: All work was done in the animal laboratory at the Alfred I. DuPont Hospital for Children. SUBJECTS: Neonatal piglets (2-8 days old; 2.5 ± 0.4 kg) were intubated and randomized to four groups (n = 8 each) to be followed over 4 hrs. Groups were control (not reintubated), injured (reintubated every 0.5 hr), intratracheal pretreatment with 1 mg of nebulized budesonide (intratracheal pretreated), or intravenous pretreatment with 0.3 mg/kg of dexamethasone (intravenous pretreated). INTERVENTION: Each pig was sedated for the duration of study and had a 3.5F catheter inserted in the femoral artery for blood sampling and blood pressure measurement every hour. After 4 hrs, each pig was killed, and tissue was harvested for histology and interleukin-6 assays. MEASUREMENTS AND MAIN RESULTS: Laryngeal tissue interleukin-6 content was greater in the injured group compared with the control group (p < .05). In the intratracheal pretreated group, the interleukin-6 content of laryngeal tissue was greater compared with the control group (p < .05), whereas the intravenous pretreated group was not different from the control group. The reintubation injury resulted in plasma interleukin-6 levels that, compared with control, were greater in the injured and intratracheal pretreated groups (p < .05). Quantitative histology showed that the degree of tracheal injury was higher in injured and intratracheal pretreated groups compared with the control group (p < .05). CONCLUSIONS: Repeated intubation alone results in significant tracheal trauma and systemic inflammation. Intravenous but not inhaled steroids attenuated the injury.

Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 Step Campaign to Prevent Antimicrobial Resistance.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) 12-Step Campaign to Prevent Antimicrobial Resistance was launched to educate clinicians about antimicrobial resistance and provide strategies to improve clinical practice, including antimicrobial utilization. METHODS: A multicenter retrospective observational study of antibiotic use was performed in 4 tertiary care NICUs to assess adherence to the guidelines defined by the CDC 12-Step Campaign using predetermined criteria. Fifty infants per NICU were identified who received intravenous antibiotics at greater than 72 hours of age. Antibiotic regimens, clinical and microbiologic data, and indications for initiation and continuation of antibiotics (after 72 hours of use) were recorded. Inappropriate utilization was characterized at initiation, continuation, by agent, and by CDC 12-Step. RESULTS: Two hundred neonates received 323 antibiotic courses totaling 3344 antibiotic-days. Ninety (28%) courses and 806 (24%) days were judged to be nonadherent to a CDC 12-Step. Inappropriate use was more common with continuation of antibiotics (39%) than with initiation (4%) of therapy. Vancomycin was the most commonly used drug (n = 895 antibiotic-days) of which 284 (32%) days were considered inappropriate. Carbapenems were used less frequently (n = 310 antibiotic-days), and 132 (43%) of these days were inappropriate. Common reasons for nonadherence at the time of continuation included failure to narrow antibiotic coverage after microbiologic results were known and prolonged antibiotic prophylaxis after surgery with chest tube placement. CONCLUSIONS: The CDC 12-Step Campaign can be modified for neonatal populations. Inappropriate antibiotic prescribing was common in the study NICUs. Improvement efforts should target antibiotic use 72 hours after initiation, particularly focusing on narrowing therapy and instituting protocols to limit prophylaxis.