Decreasing Unplanned Extubation in the Neonatal ICU With a Focus on Endotracheal Tube Tip Position.

BACKGROUND: Unplanned extubation (UE) is an important quality metric in the neonatal ICU that is associated with hypoxia, bradycardia, and risk for airway trauma with emergent re-intubation. Initial efforts to reduce UE in our level 4 neonatal ICU included standardized securement of the endotracheal tube (ETT) and requiring multiple providers to be present for ETT adjustments and patient positioning as phase 1 interventions. After an initial decline, the UE rate plateaued; an internal retrospective review revealed that the odds of UE were 2.9 times higher in the setting of an ETT tip at or above T1 (high ETT) on chest radiograph just prior to UE. The team hypothesized that advancing ETT tips to below T1 would reduce UE risk in infants of all gestational ages. METHODS: Over a period of 32 months, we compared pre-intervention and post-intervention UE rates in our neonatal ICU after a 2-step initiative that focused initially on ETT securement and assessment, with a subsequent addition of a single intervention to advance ETT tips below T1. To determine if the decrease in UE rate could be secondary to our intervention, data were analyzed from 3 cohorts: a control group of 40 infants with 185 chest radiographs and no UEs, 46 infants with chest radiographs prior to 58 UE events before the intervention, and 37 infants with chest radiographs prior to 48 UE events following the intervention. RESULTS: Advancing ETT tips below T1, in addition to the use of a standard UE-prevention bundle, led to a significant decrease in the UE rate from 1.23 to 0.91 UEs per 100 ventilator days, with 14% of postintervention UEs attributed to ETT advancement. CONCLUSIONS: High ETTs are significantly associated with UEs in the neonatal ICU. Optimizing ETT position may be an underrecognized driver in the provider's toolbox to reduce UEs. Because ETT repositioning carries risk of UE, extra caution should be taken during advancement.

Diagnoses of suspected cancer in otolaryngology practices in Germany.

The aim of this study was to estimate the prevalence of suspected head and neck cancer (HNC) diagnoses made by otolaryngologists in a population with subsequently confirmed cancer diagnoses in Germany. This study included patients with an initial documentation of confirmed cancer diagnosis made in 137 otolaryngology practices between January 2012 and December 2016 (index date). The main outcome of the study was the prevalence of diagnoses of suspected cancer in otolaryngology practices within one year prior to the first documentation of a confirmed cancer diagnosis. The association between the defined demographic and clinical variables with diagnoses of suspected cancer was analyzed using a logistic regression model. A total of 6,446 patients received a confirmed cancer diagnosis. A total of 23.1% of the population received a diagnosis of suspected cancer within 12 months prior to the first documentation of a confirmed cancer diagnosis. Patients over the age of 50 (ORs ranging from 1.44 to 1.55) and men (OR=1.52) were more likely to receive a diagnosis of suspected cancer compared with patients aged 50 or under and women. Cancer of the pyriform sinus (OR=3.00) and cancer of the thyroid gland (OR=0.27) were associated with increased and decreased odds of a diagnosis of suspected cancer compared to laryngeal cancer respectively. Overall, approximately 23% of individuals received a diagnosis of suspected cancer within a year prior to the first documentation of confirmed HNC.

Frequency of Thyroid-Stimulating Hormone Monitoring in Patients After Thyroidectomy: A Retrospective Study in Primary Care Practices in Germany.

AIM: The goal of this study was to analyze the frequency of thyroid-stimulating hormone (TSH) monitoring in thyroidectomy patients followed by general practitioners in Germany. METHODS: This study included all individuals ≥18 years who had undergone a thyroidectomy between 2000 and 2015 in 258 general practices in Germany. Another inclusion criterion was a minimum of three medical visits between 2015 and 2016, following thyroidectomy. The primary outcome was the annual frequency of TSH monitoring in thyroidectomy patients in 2015. Demographic data included age, sex, and type of health insurance coverage (private versus statutory). Clinical and therapeutic data included the amount of time since the first thyroidectomy, thyroidectomy-associated diagnosis (thyroid cancer, noncancerous enlargement of the thyroid (goiter), or hyperthyroidism), type of thyroidectomy (total or hemithyroidectomy), the Charlson Comorbidity Index score, and the prescription of levothyroxine therapy in 2015. A multivariable logistic regression model was performed to identify variables potentially associated with the likelihood of having been tested at least once for TSH in the year 2015. RESULTS: The present study included 1,135 thyroidectomy patients. The mean age was 60.1 years (SD=14.3 years), and 75.8% of the patients were women. TSH was measured at least once in 42.3% of patients. In addition, 31.5% of individuals after thyroidectomy had mean TSH values between 0.25 and 1 mIU/L in 2015. No variable was significantly associated with the frequency of TSH monitoring. However, there was a tendency toward a lower TSH monitoring frequency in the groups which had undergone thyroidectomy years ago (OR=0.77 (95% CI: 0.53-1.11) for 1-5 years and OR=0.67 (95% CI: 0.45-0.99) for>5 years compared to<=1 year). CONCLUSIONS: Only 40% of thyroidectomy patients followed by general practitioners in Germany were monitored at least once for TSH in 2015.

An evidence-based review of hyperbilirubinemia in the late preterm infant, with implications for practice: management, follow-up, and breastfeeding support.

As the incidence of late preterm births continues to rise, health care providers need to be aware of this population's unique needs. This review focuses on the additional risks late preterm infants encounter related to unconjugated hyperbilirubinemia and the importance of breastfeeding support and follow-up. Additional, population-based studies concentrating on the late preterm infant are needed to determine more clearly the incidence of hyperbilirubinemia, with specific levels documented; incidence of ED visits and rehospitalizations related to hyperbilirubinemia; and incidence of bilirubin neurotoxicity with both short- and long-term follow-up. It is also important to study these outcomes in relation to the nature and degree of risk associated with early discharge, insufficient follow-up, and breastfeeding. Future research is needed to develop evidence-based recommendations for optimal discharge timing, counseling, and postdischarge follow-up of late preterm infants, particularly those who are breastfed, to promote safe patient care.