Reducing Benzodiazepine Exposure by Instituting a Guideline for Dexmedetomidine Usage in the NICU.

BACKGROUND: Midazolam is a benzodiazepine sedative used in NICUs. Because benzodiazepine's effects include respiratory depression and potential detrimental developmental effects, minimizing exposure could benefit neonates. Dexmedetomidine is routinely used for sedation in older pediatric populations. We implemented a quality improvement initiative with the aim of decreasing midazolam infusions by 20% through use of dexmedetomidine. METHODS: A multidisciplinary committee created a sedation guideline that included standardized dexmedetomidine dosing escalation and weaning. Baseline data collection occurred from January 2015 to February 2018, with intervention from March 2018 to December 2019. Percentage of sedation episodes with dexmedetomidine initiated was followed as a process measure. Outcomes measures were percentage of eligible infants receiving midazolam infusions and midazolam-free days per sedation episode. Bradycardia with dexmedetomidine, unplanned extubation rates, and morphine dosage were monitored as balancing measures. RESULTS: Our study included 434 episodes of sedation in 386 patients. Dexmedetomidine initiation increased from 18% to 49%. The intervention was associated with a significant reduction in midazolam initiation by 30%, from 95% to 65%, with special cause variation on statistical process control chart analysis. Midazolam-free days per sedation episode increased from 0.3 to 2.2 days, and patients receiving dexmedetomidine had lower midazolam doses (1.3 mg/kg per day versus 2.2 mg/kg per day, P = 5.97 × 10-04). Bradycardia requiring discontinuation of dexmedetomidine, unplanned extubation rates, and morphine doses were unchanged. CONCLUSIONS: Implementation of a quality improvement initiative was successful in reducing the percentage of patients receiving midazolam infusions and increased midazolam-free days per sedation episode, revealing an overall reduction in benzodiazepine exposure while maintaining adequate sedation.

Screening With Reticulocyte Hemoglobin Increased Iron Sufficiency Among NICU Patients.

INTRODUCTION: To increase the rate of iron sufficiency among neonatal intensive care unit (NICU) patients from 16% to >35% within 12 months of implementing standardized assessment of reticulocyte hemoglobin (retHE). METHODS: We implemented a quality improvement (QI) study to improve iron sufficiency in our out-born level III/IV NICU. We screened 2,062 admissions, of which 622 were eligible based on feeding status at discharge. QI interventions included educational efforts and guideline implementation. Our primary outcome measure was the percentage of patients with their discharge retHE measure within the normal range. We also tracked the process measure of the number of retHE tests performed and a balancing measure of the incidence of elevated retHE among patients receiving iron supplementation. Statistical process control (SPC) charts assessed for special cause variation. RESULTS: The percentage of patients with a retHe within the normal range was significantly increased from a mean of 20% to 39% on SPC chart analysis. We measured significantly more retHE values after guideline implementation (11/mo to 24/mo) and found no cases of elevated retHE among patients receiving iron supplementation. CONCLUSIONS: After the implementation of a standardized guideline, a higher rate of iron sufficiency was found in NICU patients at discharge. This work is generalizable to neonatal populations with the potential for a significant impact on clinical practice.

The advective origin of an under-ice spring bloom in the Arctic Ocean using multiple observational platforms.

Under-ice blooms of phytoplankton in the Chukchi Sea have been observed, with strong implications for our understanding of the production regimes in the Arctic Ocean. Using a combination of satellite remote sensing of phytoplankton biomass, in situ observations under sea ice from an autonomous underwater vehicle (AUV), and in vivo photophysiology, we examined the composition, magnitude and origin of a bloom detected beneath the sea ice Northwest of Svalbard (Southern Yermak Plateau) in May 2010. In situ concentration of up to 20 mg chlorophyll a [Chl a] m-3, were dominated by the northern planktonic spring species of diatoms, Thalassiosira nordenskioeldii, T. antarctica var. borealis, Chaetoceros socialis species complex and Fragilariopsis oceanica. These species were also found south of the marginal ice zone (MIZ). Cells in the water column under the sea ice were typically high-light acclimated, with a mean light saturation index (E k ) of 138 µmol photons m-2 s-1 and a ratio between photoprotective carotenoids (PPC) and Chl a (w:w) of 0.2. Remotely sensed data of [Chl a] showed a 32,000 km2 bloom developing south of the MIZ. In effect, our data suggest that the observed under-ice bloom was in fact a bloom developed in open waters south of the ice edge, and that a combination of northward-flowing water masses and southward drifting sea ice effectively positioned the bloom under the sea ice. This have implications for our general understanding of under-ice blooms, suggesting that their origin and connection with open water may be different in different regions of the Arctic.

Bioluminescence as an ecological factor during high Arctic polar night.

Bioluminescence commonly influences pelagic trophic interactions at mesopelagic depths. Here we characterize a vertical gradient in structure of a generally low species diversity bioluminescent community at shallower epipelagic depths during the polar night period in a high Arctic fjord with in situ bathyphotometric sampling. Bioluminescence potential of the community increased with depth to a peak at 80 m. Community composition changed over this range, with an ecotone at 20-40 m where a dinoflagellate-dominated community transitioned to dominance by the copepod Metridia longa. Coincident at this depth was bioluminescence exceeding atmospheric light in the ambient pelagic photon budget, which we term the bioluminescence compensation depth. Collectively, we show a winter bioluminescent community in the high Arctic with vertical structure linked to attenuation of atmospheric light, which has the potential to influence pelagic ecology during the light-limited polar night.

Predator-guided sampling reveals biotic structure in the bathypelagic.

We targeted a habitat used differentially by deep-diving, air-breathing predators to empirically sample their prey's distributions off southern California. Fine-scale measurements of the spatial variability of potential prey animals from the surface to 1,200 m were obtained using conventional fisheries echosounders aboard a surface ship and uniquely integrated into a deep-diving autonomous vehicle. Significant spatial variability in the size, composition, total biomass, and spatial organization of biota was evident over all spatial scales examined and was consistent with the general distribution patterns of foraging Cuvier's beaked whales (Ziphius cavirostris) observed in separate studies. Striking differences found in prey characteristics between regions at depth, however, did not reflect differences observed in surface layers. These differences in deep pelagic structure horizontally and relative to surface structure, absent clear physical differences, change our long-held views of this habitat as uniform. The revelation that animals deep in the water column are so spatially heterogeneous at scales from 10 m to 50 km critically affects our understanding of the processes driving predator-prey interactions, energy transfer, biogeochemical cycling, and other ecological processes in the deep sea, and the connections between the productive surface mixed layer and the deep-water column.

Climate-driven sympatry may not lead to foraging competition between congeneric top-predators.

Climate-driven sympatry may lead to competition for food resources between species. Rapid warming in the West Antarctic Peninsula (WAP) is coincident with increasing gentoo penguin and decreasing Adélie penguin populations, suggesting that competition for food may exacerbate the Adélie penguin decline. On fine scales, we tested for foraging competition between these species during the chick-rearing period by comparing their foraging behaviors with the distribution of their prey, Antarctic krill. We detected krill aggregations within the horizontal and vertical foraging ranges of Adélie and gentoo penguins, and found that krill selected for habitats that balance the need to consume food and avoid predation. In overlapping Adélie and gentoo penguin foraging areas, four gentoo penguins switched foraging behavior by foraging at deeper depths, a strategy which limits competition with Adélie penguins. This suggests that climate-driven sympatry does not necessarily result in competitive exclusion of Adélie penguins by gentoo penguins. Contrary to a recent theory, which suggests that increased competition for krill is one of the major drivers of Adélie penguin population declines, we suggest that declines in Adélie penguins along the WAP are more likely due to direct and indirect climate impacts on their life histories.

Unexpected Levels of Biological Activity during the Polar Night Offer New Perspectives on a Warming Arctic.

The current understanding of Arctic ecosystems is deeply rooted in the classical view of a bottom-up controlled system with strong physical forcing and seasonality in primary-production regimes. Consequently, the Arctic polar night is commonly disregarded as a time of year when biological activities are reduced to a minimum due to a reduced food supply. Here, based upon a multidisciplinary ecosystem-scale study from the polar night at 79°N, we present an entirely different view. Instead of an ecosystem that has entered a resting state, we document a system with high activity levels and biological interactions across most trophic levels. In some habitats, biological diversity and presence of juvenile stages were elevated in winter months compared to the more productive and sunlit periods. Ultimately, our results suggest a different perspective regarding ecosystem function that will be of importance for future environmental management and decision making, especially at a time when Arctic regions are experiencing accelerated environmental change [1].

Is Ambient Light during the High Arctic Polar Night Sufficient to Act as a Visual Cue for Zooplankton?

The light regime is an ecologically important factor in pelagic habitats, influencing a range of biological processes. However, the availability and importance of light to these processes in high Arctic zooplankton communities during periods of 'complete' darkness (polar night) are poorly studied. Here we characterized the ambient light regime throughout the diel cycle during the high Arctic polar night, and ask whether visual systems of Arctic zooplankton can detect the low levels of irradiance available at this time. To this end, light measurements with a purpose-built irradiance sensor and coupled all-sky digital photographs were used to characterize diel skylight irradiance patterns over 24 hours at 79°N in January 2014 and 2015. Subsequent skylight spectral irradiance and in-water optical property measurements were used to model the underwater light field as a function of depth, which was then weighted by the electrophysiologically determined visual spectral sensitivity of a dominant high Arctic zooplankter, Thysanoessa inermis. Irradiance in air ranged between 1-1.5 x 10-5 µmol photons m-2 s-1 (400-700 nm) in clear weather conditions at noon and with the moon below the horizon, hence values reflect only solar illumination. Radiative transfer modelling generated underwater light fields with peak transmission at blue-green wavelengths, with a 465 nm transmission maximum in shallow water shifting to 485 nm with depth. To the eye of a zooplankter, light from the surface to 75 m exhibits a maximum at 485 nm, with longer wavelengths (>600 nm) being of little visual significance. Our data are the first quantitative characterisation, including absolute intensities, spectral composition and photoperiod of biologically relevant solar ambient light in the high Arctic during the polar night, and indicate that some species of Arctic zooplankton are able to detect and utilize ambient light down to 20-30m depth during the Arctic polar night.

Integrated environmental mapping and monitoring, a methodological approach to optimise knowledge gathering and sampling strategy.

New technology has led to new opportunities for a holistic environmental monitoring approach adjusted to purpose and object of interest. The proposed integrated environmental mapping and monitoring (IEMM) concept, presented in this paper, describes the different steps in such a system from mission of survey to selection of parameters, sensors, sensor platforms, data collection, data storage, analysis and to data interpretation for reliable decision making. The system is generic; it can be used by authorities, industry and academia and is useful for planning- and operational phases. In the planning process the systematic approach is also ideal to identify areas with gap of knowledge. The critical stages of the concept is discussed and exemplified by two case studies, one environmental mapping and one monitoring case. As an operational system, the IEMM concept can contribute to an optimised integrated environmental mapping and monitoring for knowledge generation as basis for decision making.

Adélie penguin foraging location predicted by tidal regime switching.

Penguin foraging and breeding success depend on broad-scale environmental and local-scale hydrographic features of their habitat. We investigated the effect of local tidal currents on a population of Adélie penguins on Humble Is., Antarctica. We used satellite-tagged penguins, an autonomous underwater vehicle, and historical tidal records to model of penguin foraging locations over ten seasons. The bearing of tidal currents did not oscillate daily, but rather between diurnal and semidiurnal tidal regimes. Adélie penguins foraging locations changed in response to tidal regime switching, and not to daily tidal patterns. The hydrography and foraging patterns of Adélie penguins during these switching tidal regimes suggest that they are responding to changing prey availability, as they are concentrated and dispersed in nearby Palmer Deep by variable tidal forcing on weekly timescales, providing a link between local currents and the ecology of this predator.

Evolution of the Arctic Calanus complex: an Arctic marine avocado?

Before man hunted the large baleen whales to near extinction by the end of the nineteenth century, Arctic ecosystems were strongly influenced by these large predators. Their main prey were zooplankton, among which the calanoid copepod species of the genus Calanus, long considered key elements of polar marine ecosystems, are particularly abundant. These herbivorous zooplankters display a range of adaptations to the highly seasonal environments of the polar oceans, most notably extensive energy reserves and seasonal migrations to deep waters where the non-feeding season is spent in diapause. Classical work in marine ecology has suggested that slow growth, long lifespan and large body size in zooplankton are specific adaptations to life in cold waters with short and unpredictable feeding seasons. Here, we challenge this understanding and, by using an analogy from the evolutionary and contemporary history of the avocado, argue that predation pressure by the now nearly extinct baleen whales was an important driving force in the evolution of life history diversity in the Arctic Calanus complex.

Bioluminescence in the sea.

Bioluminescence spans all oceanic dimensions and has evolved many times--from bacteria to fish--to powerfully influence behavioral and ecosystem dynamics. New methods and technology have brought great advances in understanding of the molecular basis of bioluminescence, its physiological control, and its significance in marine communities. Novel tools derived from understanding the chemistry of natural light-producing molecules have led to countless valuable applications, culminating recently in a related Nobel Prize. Marine organisms utilize bioluminescence for vital functions ranging from defense to reproduction. To understand these interactions and the distributions of luminous organisms, new instruments and platforms allow observations on individual to oceanographic scales. This review explores recent advances, including the chemical and molecular, phylogenetic and functional, community and oceanographic aspects of bioluminescence.

How do polar marine ecosystems respond to rapid climate change?

Climate change will alter marine ecosystems; however, the complexity of the food webs, combined with chronic undersampling, constrains efforts to predict their future and to optimally manage and protect marine resources. Sustained observations at the West Antarctic Peninsula show that in this region, rapid environmental change has coincided with shifts in the food web, from its base up to apex predators. New strategies will be required to gain further insight into how the marine climate system has influenced such changes and how it will do so in the future. Robotic networks, satellites, ships, and instruments mounted on animals and ice will collect data needed to improve numerical models that can then be used to study the future of polar ecosystems as climate change progresses.

Platform effects on optical variability and prediction of underwater visibility.

We present hydrographic and optical data collected concurrently from two different platforms, the R/P FLoating Instrument Platform and the R/V Kilo Moana, located about 2km apart in the Santa Barbara Channel in California. We show that optical variability between the two platforms was due primarily to platform effects, specifically the breakdown of stratification from mixing by the hull of R/P FLIP. Modeled underwater radiance distribution differed by as much as 50% between the two platforms during stratified conditions. We determine that the observed optical variability resulted in up to 57% differences in predicted horizontal visibility of a black target.

Observation of nanosecond laser induced fluorescence of in vitro seawater phytoplankton.

Seawater has been irradiated using a train of 70 ns flashes from a 440 nm laser source. This wavelength is on resonance with the blue absorption peak of Chlorophyll pigment associated with the photosystem of in vitro phytoplankton. The resulting fluorescence at 685 nm is instantaneously recorded during each laser pulse using a streak camera. Delayed fluorescence is observed, yielding clues about initiation of the photosynthetic process on a nanosecond time scale. Further data processing allows for determination of the functional absorption cross section, found to be 0.0095 A(2), which is the first reporting of this number for in vitro phytoplankton. Unlike other flash-pump studies of Chlorophyll, using a LED or flashlamp-based sources, the short laser pulse used here does not reveal any pulse-to-pulse hysteresis (i.e., variable fluorescence), indicating that the laser pulses used here are not able to drive the photosynthetic process to completion. This is attributed to competition from a back reaction between the photoexcited photosystem II and the intermediate electron acceptor. The significance of this work as a new type of deployable ocean fluorimeter is discussed, and it is believed the apparatus will have applications in thin-layer phytoplankton research.

High latitude changes in ice dynamics and their impact on polar marine ecosystems.

Polar regions have experienced significant warming in recent decades. Warming has been most pronounced across the Arctic Ocean Basin and along the Antarctic Peninsula, with significant decreases in the extent and seasonal duration of sea ice. Rapid retreat of glaciers and disintegration of ice sheets have also been documented. The rate of warming is increasing and is predicted to continue well into the current century, with continued impacts on ice dynamics. Climate-mediated changes in ice dynamics are a concern as ice serves as primary habitat for marine organisms central to the food webs of these regions. Changes in the timing and extent of sea ice impose temporal asynchronies and spatial separations between energy requirements and food availability for many higher trophic levels. These mismatches lead to decreased reproductive success, lower abundances, and changes in distribution. In addition to these direct impacts of ice loss, climate-induced changes also facilitate indirect effects through changes in hydrography, which include introduction of species from lower latitudes and altered assemblages of primary producers. Here, we review recent changes and trends in ice dynamics and the responses of marine ecosystems. Specifically, we provide examples of ice-dependent organisms and associated species from the Arctic and Antarctic to illustrate the impacts of the temporal and spatial changes in ice dynamics.

CORRELATED EVOLUTION OF GENOME SIZE AND CELL VOLUME IN DIATOMS (BACILLARIOPHYCEAE)(1).

A correlation between genome size and cell volume has been observed across diverse assemblages of eukaryotes. We examined this relationship in diatoms (Bacillariophyceae), a phylum in which cell volume is of critical ecological and biogeochemical importance. In addition to testing whether there is a predictive relationship across extant species, we tested whether evolutionary divergences in genome size were correlated with evolutionary divergences in cell size (using independent contrasts). We estimated total DNA content for 16 diatom species using a flow cytometer and estimated cell volumes using critical dimensions with scaling equations. Our independent contrast analyses indicated a significant correlated evolution between genome size and cell volume. We then explored the evolutionary and ecological implications of this evolutionary relationship. Diatom cell volume is an important component of the global carbon cycle; therefore, understanding the mechanisms that drive diatom genome evolution has both evolutionary and ecological importance.

OLIGONUCLEOTIDE PRIMERS FOR THE DETECTION OF BIOLUMINESCENT DINOFLAGELLATES REVEAL NOVEL LUCIFERASE SEQUENCES AND INFORMATION ON THE MOLECULAR EVOLUTION OF THIS GENE(1).

Bioluminescence is reported in members of 18 dinoflagellate genera. Species of dinoflagellates are known to have different bioluminescent signatures, making it difficult to assess the presence of particular species in the water column using optical tools, particularly when bioluminescent populations are in nonbloom conditions. A "universal" oligonucleotide primer set, along with species and genus-specific primers specific to the luciferase gene were developed for the detection of bioluminescent dinoflagellates. These primers amplified luciferase sequences from bioluminescent dinoflagellate cultures and from environmental samples containing bioluminescent dinoflagellate populations. Novel luciferase sequences were obtained for strains of Alexandrium cf. catenella (Whedon et Kof.) Balech and Alexandrium fundyense Balech, and also from a strain of Gonyaulax spinifera (Clap. et Whitting) Diesing, which produces bioluminescence undetectable to the naked eye. The phylogeny of partial luciferase sequences revealed five significant clades of the dinoflagellate luciferase gene, suggesting divergence among some species and providing clues on their molecular evolution. We propose that the primers developed in this study will allow further detection of low-light-emitting bioluminescent dinoflagellate species and will have applications as robust indicators of dinoflagellate bioluminescence in natural water samples.

Continuous hyperspectral absorption measurements of colored dissolved organic material in aquatic systems.

The majority of organic carbon in the oceans is present as dissolved organic matter (DOM); therefore understanding the distribution and dynamics of DOM is central to understanding global carbon cycles. Describing the time-space variability in colored dissolved organic matter (CDOM) has been difficult, as standard spectrophotometric methods for CDOM determination are laborious and susceptible to methodological biases. Previously, measurements of CDOM absorption in discrete water samples by use of a liquid-waveguide capillary cell (LWCC) compared favorably with measurements made with a benchtop spectrophotometer. Given this, we focused on automating the LWCC technique to improve our spatial and temporal sampling capabilities for CDOM. We found strong correlations between CDOM absorption spectra collected from discrete water samples using standard methods and selected corresponding CDOM spectra collected by the automated LWCC system. The near-continuous measurements by the LWCC system made it possible to map the temporal, spatial, and spectral variability of CDOM absorption along the ship track.