The Landscape of Resource Utilization After Resuscitation of 22-, 23-, and 24-Weeks' Gestation Infants.

OBJECTIVE: To compare estimated healthcare resources needed to care for 22 through 24 weeks' gestation infants. STUDY DESIGN: This multicenter, retrospective cohort study included 1505 live in-born and out-born infants 22 through 24 weeks' gestational age at delivery from 6 pediatric tertiary care hospitals from 2011 through 2020. Median neonatal intensive care unit (NICU) length of stay (LOS) for each gestational age was used as a proxy for hospital resource utilization, and the number of comorbidities and medical technology use for each infant were used as estimates of future medical care needs. Data were analyzed using Kruskal-Wallis with Nemenyi's posthoc test and Fisher's exact test. RESULTS: Of the identified newborns, 22-week infants had shorter median LOS than their 23- and 24-week counterparts due to low survival rates. There was no significant difference in LOS for surviving 22-week infants compared with surviving 23-week infants. Surviving 22-week infants had similar proportions of comorbidities and medical technology use as 23-week infants. CONCLUSIONS: Compared with 23- and 24-week infants, 22-week infants did not use a disproportionate amount of hospital resources. Twenty-two-week infants should not be excluded from resuscitation based on concern for increased hospital care and medical technology requirements. As overall resuscitation efforts and survival rates increase for 22-week infants, future research will be needed to assess the evolution of these results.

Scholarly Activity during Neonatal-Perinatal Medicine Fellowship.

OBJECTIVE: This study aimed to describe scholarly activity training during neonatal-perinatal medicine (NPM) fellowship and factors associated with scholarship productivity. STUDY DESIGN: NPM fellowship program directors (FPDs) were surveyed between March and October 2019, as part of a larger study of all pediatric subspecialty programs, to define barriers, resources, and productivity for fellow scholarly activity. High productivity was defined as >75% of fellows in a program in the last 5 years having a manuscript accepted for publication based on fellowship scholarly work. RESULTS: Fifty-four percent (54/100) of NPM FPDs completed the survey. Nineteen fellowship programs (35%, 19/54) met the definition for high productivity. High productivity in scholarly activity was associated with a greater likelihood of having funds to conduct scholarship (p = 0.011), more protected months dedicated to scholarly activity (p = 0.03), and fellow extramural grant applications (submitted or accepted, p = 0.047). FPDs of productive programs were less likely to report lack of an adequate core research curriculum (p = 0.018), lack of adequate expertise on the fellowship scholarly oversight committee (p = 0.048), and lack of sufficient divisional mentorship (p = 0.048) as barriers to completion of scholarly activity during fellowship. CONCLUSION: Research funding, protected research time, established research mentors, and a research curriculum are associated with higher scholarly activity productivity among NPM fellowship programs. Further investment in these resources may improve scholarly activity productivity during fellowship training. KEY POINTS: · Fellow productivity depends on protected time.. · Inadequate funding impacts fellow productivity.. · Mentorship is important for fellow scholarship.. · A research curriculum impacts research outcomes..

A national virtual job search series for neonatal-perinatal medicine fellows.

BACKGROUND: A standardized approach to prepare trainees for the job search has not been described. The objective of this study was to describe and evaluate an educational series on the job search for Neonatal-Perinatal Medicine (NPM) fellows and identify participants' job search knowledge gaps. METHODS: During the 2020-2021 academic year, we created a virtual, seven-part job search series for NPM fellows that required no funding. The series has been repeated annually. We use REDCap surveys to register participants, collect baseline/demographic information, and evaluate the series' impact at the beginning and end of the job search timeline. RESULTS: In the 2021-2022 academic year, 290 individuals registered for the series, and 89% completed the baseline/demographic survey. The majority were NPM fellows (89%). Early career neonatologists, NPM hospitalists, and pediatric residents also utilized the series (11%). Less than 25% reported being "knowledgeable" or "very knowledgeable" of core job search components, including the timeline of the job search, contract negotiation, and the general roles and responsibilities of junior faculty. Of those who completed the final job search survey and underwent a job search (60%, 97 of 162), the majority (86%) felt that career planning during training was stressful and believed that job search preparation should be structured into the NPM fellowship curriculum (81%). Many felt that the Job Search Series was helpful in elucidating components of the job search. CONCLUSIONS: We identified several knowledge gaps in NPM fellows' understanding of how to find, prepare for, and negotiate their first post-training job. We strongly believe these knowledge gaps are not unique to NPM fellows and that all graduate medical education trainees would benefit from a similar, easy-to-implement, no-cost series.

Shifting Provider Attitudes and Institutional Resources Surrounding Resuscitation at the Limit of Gestational Viability.

OBJECTIVE: This study aimed to provide contemporary data regarding provider perceptions of appropriate care for resuscitation and stabilization of periviable infants and institutional resources available to providers. STUDY DESIGN: A Qualtrics survey was emailed to 672 practicing neonatologists in the United States by use of public databases. Participants were asked about appropriate delivery room care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making, and resources utilized regarding resuscitation. Descriptive statistics were used to analyze the dataset. RESULTS: In total, 180 responses were received, and 173 responses analyzed. Regarding preferred course of care based on gestational age, the proportion of respondents endorsing full resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%, 23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors most impacting decision-making at 22 weeks gestational age included: outcomes based on population data (79%), parental wishes (65%), and quality of life measures (63%). Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the delivery room (77%), and vascular access (69%) were the most supported therapies for initial stabilization. Availability of institutional resources varied; the most limited were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care teams (54%). CONCLUSION: There appears to be discordance in provider attitudes surrounding preferred actions at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability and identified resource limitations are nonuniform. Between-hospital variations in outcomes for periviable infants may be partly attributable to lack of provider consensus and nonuniform resource availability across institutions. KEY POINTS: · Within the past decade, there has been a shift in the gray zone from 23-24 to 22-23 weeks gestation.. · Attitudes around resuscitation of infants are nonuniform despite perceived standardized approaches.. · Institutional variability in resources may contribute to variation in outcomes of periviable infants..

Changes, Challenges, and Variations in Neonatal-Perinatal Medicine Fellowship: A View from the Program Directors.

OBJECTIVE: Neonatal-perinatal medicine (NPM) fellowship programs in the United States support >800 learners annually. Understanding variations in the programmatic structure, challenges, and needs is essential to optimize the educational environment and ensure the specialty's future. STUDY DESIGN: NPM fellowship program directors (PDs) and associate program directors (APDs) were invited to complete an electronic survey on their program administration, recruitment, clinical training, assessment methods, scholarly program, and career pathways. Each participant identified individual programmatic strengths, challenges, opportunities, and threats to the field. RESULTS: Representatives from 59 NPM fellowships provided data (response rate 59/96 = 61%). In total, 30% of PDs received less than the Accreditation Council for Graduate Medical Education -recommended protected time for administrative duties, and 44% of APDs received no protected time. Fellow clinical service assignments varied widely from 13 to 18 months and 90 to 175 call nights over 3 years. Recruitment practices varied across programs; 59% of respondents raised concerns over the pipeline of applicants. Conflicts between fellows and advanced practice providers were identified by 61% of responders. Programs varied in their scholarly offerings, with 44% of NPM fellowships interested in adding broader research opportunities. CONCLUSIONS: NPM fellowship leaders identified a need for improved programmatic support, enhanced measures to assess competency, opportunities to strengthen scholarly programs, shared curricular resources, and strategies to balance education with clinical demands. PDs and APDs identified threats to the future of NPM training programs including the diminishing pipeline of applicants into neonatology, challenges with clinical exposure and competence, inadequate support for the educational mission, issues supporting high-quality scholarship, and fewer graduates pursuing physician-investigator pathways. National organizations and academic institutions should take action to address these challenges so that fellowships can optimally prepare graduates to meet their patients' needs. KEY POINTS: · Numerous challenges exist for current program directors in NPM including balancing clinical work with scholarly activities, accurately assessing competency, optimizing the culture of the learning environment, and ensuring that fellows are adequately prepared for a range of postgraduate positions.. · Significant variation exists across NPM fellowship programs in clinical service/calls assigned over 3 years of fellowship training, as well as opportunities to pursue scholarly activities across a variety of areas.. · Challenges exist related to ensuring an adequate number of future applicants into the specialty, including those from backgrounds traditionally underrepresented in medicine, as well as those seeking to pursue careers as physician-investigators..

When is My Baby Going Home? Moderate to Late Preterm Infants are Discharged at 36 Weeks Based on Admission Data.

OBJECTIVE: This study evaluates the effect of admission characteristics of uncomplicated moderate to late preterm infants on timing of discharge. One of the first questions that families of infants admitted to the Neonatal Intensive Care Unit (NICU) ask is, "When is my baby going home?" Moderate to late preterm infants are the largest cohort of NICU patients but little data exist about their length of stay (LOS). STUDY DESIGN: A retrospective electronic chart review was completed on 12,498 infants admitted to our NICU between January 1, 2009 and December 31, 2015. All inborn infants with a gestational age between 320/7 and 366/7 weeks were studied. RESULTS: A total of 3,240 infants met our inclusion criteria. The mean postmenstrual age at discharge was 363/7 weeks. Infants who were small for gestational age were significantly more likely to have an increased LOS. Infants born between 34 and 366/7 weeks had a significantly increased LOS if they had respiratory distress syndrome. Admission diagnoses of neonatal abstinence syndrome, meconium aspiration syndrome, hydrops, hypoxic ischemic encephalopathy, biliary emesis, ABO incompatibly, and a genetic diagnosis all had increased LOS for all late preterm infants. CONCLUSION: For uncomplicated moderate to late preterm infants, clinicians can counsel families that their infants will likely be discharged at 36 weeks of postmenstrual age. Small for gestational age infants and those with specific diagnoses may stay longer.

Late management of the aortic root after repair of tetralogy of Fallot: A European multicentre study.

OBJECTIVES: We sought to determine the indications, type, and outcomes of reoperations on the aortic root after repair of tetralogy of Fallot (TOF). METHODS: Eleven centers belonging to the European Congenital Heart Surgeons Association contributed to the data collection process. We included 36 patients who underwent surgical procedures on the aortic root, including surgery on the aortic valve and ascending aorta, between January 1975 and December 2017. Original diagnoses included TOF-pulmonary stenosis (n = 18) and TOF-pulmonary atresia (n = 18). The main indications for reoperation were aortic insufficiency (n = 19, 53%), aortic insufficiency and dilatation of the ascending aorta (n = 10, 28%), aortic root dilatation (n = 4, 11%), and ascending aorta dilatation (n = 3, 8%). RESULTS: The median age at reoperation was 30.4 years (interquartile range 20.3-45.3 years), and mechanical aortic valve replacement was the most common procedure performed. Five patients died early after reoperation (14%), and larger ascending aorta diameters were associated with early mortality (P = .04). The median age at the last follow-up was 41.4 years (interquartile range 24.5-51.6 years). Late death occurred in five patients (5/31, 16%). Most survivors (15/26, 58%) were asymptomatic at the last clinical examination (New York Heart Association, NYHA class I). The remaining patients were NYHA class II (n = 7) and III (n = 3). The most common symptoms were fatigue (n = 5), dyspnea (n = 4), and exercise intolerance (n = 3). CONCLUSIONS: Reoperations on the aortic root are infrequent but may become necessary late after TOF repair. The main indications for reoperation are aortic insufficiency, either isolated or associated with a dilatation of the ascending aorta. The surgical risk at reoperation was high and the presence of ascending aorta dilation is related to higher mortality.

Assessing a new coarctation repair simulator based on real patient's anatomy.

OBJECTIVES: To perform the preliminary tests of coarctation of aorta repair trainer, evaluate the surgical properties of the simulation and to assess and enhance residents' skills. METHODS: Single patient's angio-CT anatomy data were converted into magnified 3D-printed model of aortic coarctation with hypoplastic aortic arch, serving for creation of a mould used during wax copies casting. Wax cores were painted with six layers of elastic silicone and melted, yielding phantoms that were consecutively fixed in a mounting with and without a thoracic wall. Simulation included: proximal and distal aortic arch clamping, incision of its lesser curvature, extended end-to-end anastomosis with 7-0 suture. A head-mounted camera video recording enabled anastomosis time and mean one suture bite time evaluation. Leakage assessment was done by a water test. RESULTS: Two residents performed nine simulations each. Last four runs were performed with thoracic wall attached. All phantoms performed well, enabling tissue-like handling and cutting, excellent suture retention, and satisfactory elasticity. Median anastomosis times were 22'33″ and 24'47″ for phantoms without and with thoracic wall (p = not significant (NS)). Median times needed to pass suture through one side of anastomosis and regrasp needle were, respectively, 9″ and 13″ (p < 0.001). Median total number of leakages per phantom equalled 2 for both difficulty levels. There were no significant inter-resident differences in all assessed parameters. CONCLUSIONS: This medium-fidelity aortic coarctation repair trainer showed its feasibility in replication of major critical steps of the real operation. Objective surgical efficiency parameters could be obtained from each simulation and compared between trainees and at different adjustable difficulty levels.

Serelaxin for infant heart failure in congenital dilated cardiomyopathy.

Serelaxin has been studied in trials in adults with acute heart failure, but not in children. We report the first compassionate use of serelaxin in an infant. A 6-month-old girl with dilated cardiomyopathy was placed on extracorporeal membrane oxygenation following cardiac arrest unresponsive to medical treatment. Extracorporeal membrane oxygenation weaning failed despite maximal ino-dilator therapy. During the 48-hour infusion of serelaxin, we observed marked improvement in brain natriuretic peptide, left ventricular systolic function, and dilatation. The patient was successfully weaned from extracorporeal membrane oxygenation 24 hours later. The child died after a second extracorporeal membrane oxygenation run owing to sepsis.

Population-Based Outcomes Data for Counseling at the Margin of Gestational Viability.

OBJECTIVE: To survey neonatologists as to how many use population-based outcomes data to counsel families before and after the birth of 22- to 25-week preterm infants. STUDY DESIGN: An anonymous online survey was distributed to 1022 neonatologists in the US. Questions addressed the use of population-based outcome data in prenatal and postnatal counseling. RESULTS: Ninety-one percent of neonatologists reported using population-based outcomes data for counseling. The National Institute of Child Health and Human Development Neonatal Research Network Outcomes Data is most commonly used (65%) with institutional databases (14.5%) the second choice. Most participants (89%) reported that these data influence their counseling, but it was less clear whether specific estimates of mortality and morbidity influenced families; 36% of neonatologist felt that these data have little or no impact on families. Seventy-one percent reported that outcomes data estimates confirmed their own predictions, but among those who reported having their assumptions challenged, most had previously been overly pessimistic. Participants place a high value on gestational age and family preference in counseling; however, among neonatologists in high-volume centers, the presence of fetal complications was also reported to be an important factor. A large portion of respondents reported using prenatal population-based outcomes data in the neonatal intensive care unit. CONCLUSION: Despite uncertainty about their value and impact, neonatologists use population-based outcomes data and provide specific estimates of survival and morbidity in consultation before and after extremely preterm birth. How best to integrate these data into comprehensive, family-centered counseling of infants at the margin of viability is an important area of further study.

A Comparison of Prenatal and Postnatal Models to Predict Outcomes at the Border of Viability.

OBJECTIVE: To compare the accuracy of a prenatal outcomes calculator developed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) with a postnatal neonatal intensive care unit (NICU) prediction model for mechanically ventilated infants. STUDY DESIGN: Over a 3-year period, we identified 89 ventilated infants born in our NICU between 23 and 25 weeks gestation. We retrospectively determined the predicted morbidity and mortality for each infant using the prenatal NICHD Neonatal Research Network: Extremely Preterm Birth Outcome Data website calculator. For our postnatal prediction model, we assessed 2 factors while each infant was on mechanical ventilation: daily intuitions about whether the infant would die before NICU discharge and abnormal head ultrasound. We compared the prenatal and postnatal models for predicting outcomes at 2 years adjusted age. RESULTS: Of the 89 infants, 54 (61%) died or had neurologic developmental impairment (NDI) and 35 (39%) survived without NDI. The NICHD Neonatal Research Network: Extremely Preterm Birth Outcome Data website calculator predicted that 61 (69%) would either die or have NDI and that 28 (31%) would survive without NDI. Positive clinicians' intuitions about survival combined with normal head ultrasound scan results during a trial of therapy in the NICU predicted a 30% greater chance for survival without NDI than the prenatal tool. CONCLUSIONS: When infants at the border of viability are born and cared for in the NICU, they move from predictions for population-based outcomes into predictions based on individual trajectories and outcomes. A clinical trial of therapy provides additional prognostic information that can guide parental decisions made near the time of birth.

Asymptomatic right circumflex aortic arch associated with ventricular septal defect and biscuspid aortic valve.

INTRODUCTION: Anomalies of the aortic arch are frequent congenital malformations, which rarely form partial or complete vascular rings. A rare form of vascular ring is the encircling, or circumflex, aortic arch. CASE REPORT: A 19-month-old boy, with no respiratory symptoms, was referred for ventricular septal defect (VSD) repair. Cardiac magnetic resonance imaging and echocardiography confirmed the perimembranous VSD, a bicuspid aortic valve with normal function, and showed a right-sided ascending aorta, bifurcating to the left behind the esophagus and trachea above the tracheal bifurcation, with a left-sided descending aorta, a left ligamentum arteriosum and aberrant left subclavian artery, realizing a circumflex aortic arch. The child underwent successful VSD repair and ligamentum arteriosum division, with an uneventful postoperative course. CONCLUSIONS: Previous reports have described the association of circumflex aortic arch with VSD, but there is no previous report of its association with VSD and bicuspid aortic valve. Patients are usually symptomatic either preoperatively, or after VSD repair. For this reason, division of the ligamentum arteriosum, to open the vascular ring and free the trachea and esophagus from compression, should be performed in patients undergoing cardiac surgery for associated malformations.

Airway compression management in late-presenting absent pulmonary valve syndrome.

INTRODUCTION: Patients with absent pulmonary valve syndrome often present early with airway compression from aneurysmal pulmonary arteries. This study reviews our experience in managing absent pulmonary valve syndrome in later presenting children, and techniques used for managing airway compression. METHODS: This study is a retrospective chart review of all patients who underwent repair of absent pulmonary valve syndrome from 2000 to 2012 at our institution. The primary endpoints were post-operative bronchoscopic and clinical evidence of persistent airway compression and need for reinterventions on the pulmonary arteries. RESULTS: A total of 19 patients were included during the study period. The mean age at repair was 4.1±3.0 years (range 10 months-11 years). In all, seven patients had pre-operative bronchoscopic evidence of airway compression, which was managed by pulmonary artery reduction plasty in four patients and Lecompte manoeuvre in three patients. There were no peri-operative deaths. In patients with pulmonary artery plasty, two had no post-operative airway compression, one patient had improved compression, and one patient had unchanged compression. In patients managed with a Lecompte manoeuvre, two patients had no or trivial airway compression and one had improved compression. There were six late reinterventions or reoperations on the pulmonary arteries - two out of four in the pulmonary artery plasty group and one out of three in the Lecompte group. CONCLUSIONS: Most late-presenting patients with absent pulmonary valve syndrome do not have airway compression. Either pulmonary artery reduction plasty or the Lecompte manoeuvre can relieve proximal airway compression, without a significantly different risk of pulmonary artery reintervention between techniques.

Postmortem imaging of antemortem myocardial ischaemia.

OBJECTIVES: To determine the minimum survival time for detection of antemortem myocardial ischaemia with postmortem imaging (PMI) techniques. METHODS: Nine pigs underwent ligation of the left anterior descending (LAD) (8) and/or right coronary artery (RCA) branch (4), and were killed 30 min-6 h after ligation. PMI (MRI and CT angiography) was performed 2-55 h after euthanasia. Signal intensity of myocardial segments was measured. The hearts were removed, the coronary arteries injected to mark perfused segments, and sections submitted for histology. RESULTS: MRI T2-weighted sequences showed the ischaemic area as hyperintense in 4/4 LAD ligations with ≥4 h of ischaemia but in 0/4 with <4 h. Histological evidence of ischaemia was present in 4/4 animals after 4 h. Right ventricular ischaemic myocardium was visible on MRI T2-weighted sequences after 6 h of ischaemia in one animal. CT angiography showed the occluded coronary artery in all cases. CONCLUSIONS: Ischaemic lesions of the left ventricle, but not of the right, at least 4 h old can be detected as hyperintense areas on T2-weighted postmortem MRI. This technique is most sensitive in the first 24 h after death. Other sequences did not enhance detection. KEY POINTS: • Left ventricular myocardial ischaemia/infarction can be demonstrated by postmortem imaging (PMI). • Ischaemia/infarction is better detected if survival time is at least 4 h. • Right ventricular ischaemia/infarction is not reliably detected by PMI. • Computed tomography angiography can demonstrate arterial occlusion.