Spontaneous resolution of post-hemorrhagic ventricular dilatation in preterm newborns and neurodevelopment.

BACKGROUND: We investigated the temporal evolution of post-hemorrhagic ventricular dilatation (PHVD) and compared neurodevelopmental impairments (NDI) in newborns with (Group 1) spontaneous resolution of PHVD, (Group 2) persistent PHVD without neurosurgical intervention, and (Group 3) progressive PHVD receiving neurosurgical intervention. METHODS: A multicenter retrospective cohort study of newborns born at ≤34 weeks with PHVD (ventricular index [VI] >97th centile for gestational age and anterior horn width [AHW] >6 mm) from 2012 to 2020. Severe NDI was defined as global developmental delay or cerebral palsy GMFCS III-V at 18 months. RESULTS: Of 88 survivors with PHVD, 39% had a spontaneous resolution, 17% had persistent PHVD without intervention, and 44% had progressive PHVD receiving intervention. The median time between PHVD diagnosis and spontaneous resolution was 14.0 days (IQR 6.8-32.3) and between PHVD diagnosis and first neurosurgical intervention was 12.0 days (IQR 7.0-22.0). Group 1 had smaller median maximal VI (1.8, 3.4, 11.1 mm above p97; p < 0.001) and AHW (7.2, 10.8, 20.3 mm; p < 0.001) than Groups 2 and 3. Neurodevelopmental outcome data were available for 82% of survivors. Group 1 had reduced severe NDI compared to Group 3 (15% vs 66%; p < 0.001). CONCLUSION: Newborns with PHVD without spontaneous resolution are at higher risk for impairments despite neurosurgical interventions, which may be due to larger ventricular dilatation. IMPACT: The natural evolution of post-hemorrhagic ventricular dilatation (PHVD) and developmental implications of spontaneous resolution are not well established. In this study, approximately one in three newborns with PHVD experienced spontaneous resolution and this subset of newborns had reduced rates of neurodevelopmental impairments. More prominent ventricular dilatation was associated with reduced rates of spontaneous resolution and increased rates of severe neurodevelopmental impairment among newborns with PHVD. Understanding clinically relevant time points in the evolution of PHVD and predictors of spontaneous resolution may help inform the discussion around the optimal timing for intervention and allow for more precise prognostication in this population.

Factors Influencing Physician Prognosis: A Scoping Review.

Introduction. Prognosis is an essential component of informed consent for medical decision making. Research shows that physicians display discrepancies in their prognostication, leading to variable, inaccurate, optimistic, or pessimistic prognosis. Factors driving these discrepancies and the supporting evidence have not been reviewed systematically. Methods. We undertook a scoping review to explore the literature on the factors leading to discrepancies in medical prognosis. We searched Medline (Ovid) and Embase (Ovid) databases for peer-reviewed articles from 1970 to 2017. We included articles that discussed prognosis variation or discrepancy and where factors influencing prognosis were evaluated. We extracted data outlining the participants, methodology, and prognosis discrepancy information and measured factors influencing prognosis. Results. Of 4,723 articles, 73 were included in the final analysis. There was significant variability in research methodologies. Most articles showed that physicians were pessimistic regarding patient outcomes, particularly in early trainees and acute care specialties. Accuracy rates were similar across all time periods. Factors influencing prognosis were clustered in 4 categories: patient-related factors (such as age, gender, race, diagnosis), physician-related factors (such as age, race, gender, specialty, training and experience, attitudes and values), clinical situation-related factors (such as physician-patient relationship, patient location, and clinical context), and environmental-related factors (such as country or hospital size). Discussion. Obtaining accurate prognostic information is one of the highest priorities for seriously ill patients. The literature shows trends toward pessimism, especially in early trainees and acute care specialties. While some factors may prove difficult to change, the physician's personality and psychology influence prognosis accuracy and could be tackled using debiasing strategies. Exposure to long-term patient outcomes and a multidisciplinary practice setting are environmental debiasing strategies that may warrant further research. Highlights: Literature on discrepancies in physician's prognostication is heterogeneous and sparse.Literature shows that physicians are mostly pessimistic regarding patient outcomes.Literature shows that a physician's personality and psychology influence prognostic accuracy and could be improved with evidence-based debiasing strategies.Medical specialty strongly influences prognosis, with specialties exposed to acutely ill patients being more pessimistic, whereas specialties following patients longitudinally being more optimistic.Physicians early in their training were more pessimist than more experienced physicians.

Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents.

Context: Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). Purpose: To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents. Procedures: Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively. Results: Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were "usually" (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only "sometimes" accurate and only used them "sometimes" (33%) to discuss prognosis; a majority of them (66%) would "always" repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents. Conclusions: Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.

Ethical Foundations of the Accompanying Patient's Role for an Enhanced Patient Experience: A Scoping Review.

In recent years, recognizing patients' experiential knowledge to improve the quality of care has resulted in the participation of patient advisors at various levels of healthcare systems. Some who are working at the clinical level are called accompanying patients (AP). A PRISMA-ScR exploratory scoping review of the literature was conducted on articles published from 2005 to 2021. Articles not in English or French and grey literature were excluded. The databases searched included Medline, PubMed, Scopus, and Google Scholar. The data were organized according to the similarities in the ethical foundations of the included papers. Out of 2095 identified papers, 8 met inclusion criteria. Terms used to describe APs included peer support, resource parent, and peer health mediator. The clinical settings included psychiatry/mental health and neonatology. APs, patients, healthcare professionals, managers and policy makers were included in the studies. Three personal ethical foundations describing the foundations of the AP role were found: resilience, listening skills and altruism. The ethical foundations of this role also addressed interpersonal and interprofessional relationships with other actors in the healthcare system. The literature on the ethical foundations of APs is sparse, with heterogeneous methodologies. Further studies mobilizing well-defined methodologies would further validate the current results and deepen our understanding of the ethical foundations of the AP role.

Postoperative noninvasive ventilation and complications in esophageal atresia-tracheoesophageal fistula.

PURPOSE: This study examines the impact of postoperative noninvasive ventilation strategies on outcomes in esophageal atresia-tracheoesophageal fistula (EA-TEF) patients. METHODS: A single center retrospective chart review was conducted on all neonates followed at the EA-TEF Clinic from 2005 to 2017. Primary outcomes were: survival, anastomotic leak, stricture, pneumothorax, and mediastinitis. Statistical significance was determined using Chi-square and logistic regression (p ≤ .05). RESULTS: We reviewed 91 charts. Twenty-five infants (27.5%) were bridged with postextubation noninvasive ventilation (15 on Continuous Positive Airway Pressure (CPAP), 5 on Noninvasive Positive Pressure Ventilation (NIPPV), and 14 on High-Flow Nasal Cannula (HFNC)). Overall, 88 (96.7%) patients survived, 25 (35.7%) had a stricture, 14 (20%) had anastomotic leak, 9 (12.9%) had a pneumothorax, and 4 (5.7%) had mediastinitis. Use of NIPPV was associated with increased risk of mediastinitis (P = .005). Use of HFNC was associated with anastomotic leak (P = .009) and mediastinitis (P = .036). CONCLUSIONS: These data suggest that postoperative noninvasive ventilation techniques are associated with a significantly higher risk of anastomotic leak and mediastinitis. Further prospective research is needed to guide postoperative ventilation strategies in this population. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: IV.

The complexity of physicians' understanding and management of prognostic uncertainty in neonatal hypoxic-ischemic encephalopathy.

OBJECTIVE: Prognosis of Hypoxic-Ischemic Encephalopathy (HIE) remains challenging and uncertain. This paper investigates how physicians understand and address the ethical challenges of prognostic uncertainty in the case of neonatal HIE, contextualized within the social science literature. STUDY DESIGN: Semi-structured interviews were conducted with 12 Canadian neurologists and neonatologists, addressing their perspectives and clinical experiences concerning neonatal HIE prognostication. Interviews were analyzed using thematic content analysis. RESULTS: Participants unanimously recognized uncertainty in their prognostication. They identified several sources contributing to uncertainty in HIE prognostication, including etiology and underlying pathophysiologic mechanisms, statistical limitations, variable clinical data, the dynamic process of neurodevelopment, or the impact of hypothermia treatment. Unlike in some other literature, some physicians in this study talked about ways to render uncertainty explicit rather than hide it. CONCLUSION: Results from this study support the call for recognition of the ubiquitous uncertainty surrounding this act in medical education and training.

Resilience Rather than Medical Factors: How Parents Predict Quality of Life of Their Sick Newborn.

OBJECTIVE: To assess the influence of resiliency and stress on parental perspectives of the future quality of life (QOL) of neonatal intensive care unit (NICU) newborns at high risk of neurodevelopmental disability. STUDY DESIGN: We conducted a prospective multicenter questionnaire study. Perspectives from parents of newborns at high risk of disability as per neonatal follow-up criteria were compared with a low-risk group consisting of parents of all other NICU newborns. Parental anxiety and resiliency, measured using Brief Symptom Inventory and Sense of Coherence scales, respectively, were associated with QOL projections. RESULTS: Parents returned 129 (81%) questionnaires. Parents considering their newborn as currently sicker were more stressed (P = .011) and worried about future physical (P < .001) and mental (P < .001) health, QOL (P < .001), coping (P = .019), and financial (P < .001) and emotional (P = .002) impact on the family. Ooverall, there was no difference between parents of high-risk and low-risk newborns on QOL projections. Almost all parents projected a good future QOL. Less resilient parents projected more pain (P = .04), more financial (P = .019), and emotional (P = .031) impact on their family, and were 10 times more likely to predict that their newborn would remain chronically ill. CONCLUSIONS: Parental projection of future QOL of NICU newborns is not associated with risk of disability. Most parents predict overall a good future QOL and focus more on familial impact. The Sense of Coherence scale may be used in clinical settings to identify less resilient parents.

Do we need to worry about mycophenolate overdose?

INTRODUCTION: To discuss the significance of the recent observational case series from the Swiss Toxicological Information Centre (STIC). Mycophenolic acid (MPA) and its prodrug mycophenolate mofetil are immunosuppressive agents that are frequently prescribed in renal transplant recipients, and their safety profiles must be established. AREAS COVERED: This case series and systemic literature analysis consists of 15 cases of MPA overdose from the STIC and a systemic analysis of the literature over the past 18 years. This study focuses on acute overdosing, the effects of which are presumably mild. In contrast, the effects of long-term overdosing may be much more severe. Substantial underreporting is likely. The pharmacokinetic monitoring of MPA is rarely performed, which is both striking and does not coincide with findings in academic literature. The scant data on pharmacokinetic monitoring presented demonstrated that MPA has a short terminal half-life, which suggests that decontamination and activated charcoal treatment in acute overdose may not be necessary. EXPERT OPINION: The case series and systematic literature analysis of acute mycophenolate overdose represent an important contribution toward increasing the safety of MPA therapy.