Increasing in-person medical interpreter utilization in the NICU through a bundle of interventions.

BACKGROUND: In-person medical interpretation improves communication with patients who have preferred language other than English (PLOE). Multi-dimensional barriers to use of medical interpreters limit their use in the NICU. LOCAL PROBLEM: Medical teams in our NICU were not consistently using in-person medical interpreters, leading to ineffective communication with families with PLOE. METHODS/INTERVENTIONS: Interventions included staff educational sessions and grand rounds regarding equitable language access, distribution of interpreter request cards to families, and allocation of dedicated in-person interpreters for NICU rounds. Interpreter utilization was calculated by total requests per Spanish-speaking person day in the NICU. RESULTS: Interpreter utilization increased five-fold during the intervention period (from 0.2 to 1.0 requests per Spanish-speaking person day). CONCLUSIONS: We substantially increased our unit in-person interpreter utilization through a bundle of multifaceted interventions, many of which were low-cost. NICUs should regard dedicated medical interpreters as a critical part of the care team.

Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study.

OBJECTIVE: Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explored expert opinion on their etiology, potential solutions, and the ability of health equity dashboards to meaningfully capture NICU disparities. STUDY DESIGN: We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis. RESULT: We identified three sources of disparity: interpersonal bias, care process and institutional barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited, because clinical metrics do not account for many of the aforementioned sources of disparities. CONCLUSION: Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

Angiotensin-II Use for Refractory Hypotension in an Infant With Bilateral Renal Agenesis.

Infants with congenital bilateral renal agenesis are at significant risk for morbidity and mortality, despite substantial and continuing advances in fetal and neonatal therapeutics. Infants with bilateral renal agenesis may episodically develop severe hypotension that can be refractory to traditional vasopressors. Synthetic angiotensin-II has been successfully used in adult and a few pediatric patients with refractory hypotension but has not been extensively studied in infants. We describe the use of angiotensin-II in treating refractory hypotension in a premature infant with congenital bilateral renal agenesis admitted to the NICU. Within 48 hours, he no longer required other vasopressors. Subsequently, angiotensin-II was gradually weaned and discontinued over 10 days and the patient was ultimately discharged from the hospital. This case demonstrates that angiotensin-II may be a helpful agent to treat refractory hypotension in infants with bilateral renal agenesis.

Disparities and Equity Dashboards in the Neonatal Intensive Care Unit: A Qualitative Study of Expert Perspectives.

Objective: Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explore expert opinion on their root causes, potential solutions, and the ability of health equity dashboards to meaningfully address NICU disparities. Study Design: We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis. Result: Participants identified three sources of disparity: interpersonal bias, care process barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited because clinical metrics do not account for many of the aforementioned sources of disparities. Conclusion: Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

Patent foramen ovale in patients with sickle cell disease and stroke: case presentations and review of the literature.

Although individuals with sickle cell disease (SCD) are at increased risk for stroke, the underlying pathophysiology is incompletely understood. Intracardiac shunting via a patent foramen ovale (PFO) is associated with cryptogenic stroke in individuals without SCD. Recent evidence suggests that PFOs are associated with stroke in children with SCD, although the role of PFOs in adults with stroke and SCD is unknown. Here, we report 2 young adults with SCD, stroke, and PFOs. The first patient had hemoglobin SC and presented with a transient ischemic attack and a subsequent ischemic stroke. There was no evidence of cerebral vascular disease on imaging studies and the PFO was closed. The second patient had hemoglobin SS and two acute ischemic strokes. She had cerebral vascular disease with moyamoya in addition to a peripheral deep venous thrombosis (DVT). Chronic transfusion therapy was recommended, and the DVT was managed with warfarin. The PFO was not closed, and the patients' neurologic symptoms were stabilized. We review the literature on PFOs and stroke in SCD. Our cases and the literature review illustrate the dire need for further research to evaluate PFO as a potential risk factor for stroke in adults with SCD.

Necrostatin decreases oxidative damage, inflammation, and injury after neonatal HI.

Necrostatin-1 inhibits receptor-interacting protein (RIP)-1 kinase and programmed necrosis and is neuroprotective in adult rodent models. Owing to the prominence of necrosis and continuum cell death in neonatal hypoxia-ischemia (HI), we tested whether necrostatin was neuroprotective in the developing brain. Postnatal day (P)7 mice were exposed to HI and injected intracerebroventricularly with 0.1 µL of 80 µmol necrostatin, Nec-1, 5-(1H-Indol-3-ylmethyl)-(2-thio-3-methyl) hydantoin, or vehicle. Necrostatin significantly decreased injury in the forebrain and thalamus at P11 and P28. There was specific neuroprotection in necrostatin-treated males. Necrostatin treatment decreased necrotic cell death and increased apoptotic cell death. Hypoxia-ischemia enforced RIP1-RIP3 complex formation and inhibited RIP3-FADD (Fas-associated protein with death domain) interaction, and these effects were blocked by necrostatin. Necrostatin also decreased HI-induced oxidative damage to proteins and attenuated markers of inflammation coincidental with decreased nuclear factor-κB and caspase 1 activation, and FLIP ((Fas-associated death-domain-like IL-1ß-converting enzyme)-inhibitory protein) gene and protein expression. In this model of severe neonatal brain injury, we find that cellular necrosis can be managed therapeutically by a single dose of necrostatin, administered after HI, possibly by interrupting RIP1-RIP3-driven oxidative injury and inflammation. The effects of necrostatin treatment after HI reflect the importance of necrosis in the delayed phases of neonatal brain injury and represent a new direction for therapy of neonatal HI.