Strategies to Improve the Quality of Team-Based Care for Neonatal Abstinence Syndrome.

BACKGROUND: Prioritizing nonpharmacologic care for neonatal abstinence syndrome (NAS) requires a team-based care (TBC) approach to facilitate staff and family engagement. We aimed to identify the important structures and processes of care for TBC of infants with NAS and quality of care outcomes that are meaningful to care team members (including parents). METHODS: Using a Donabedian framework, we conducted semistructured interviews from May to October 2019 with care team members at 3 community hospitals, including parents, nurses, social workers, physicians, lactation nurses, child protective services, volunteers, and hospital administrators. We used thematic analysis to identify important structures, processes of care, and outcomes. RESULTS: We interviewed 45 interprofessional care team members: 35 providers and 10 parents. Structures critical to providing TBC included (1) building a comprehensive network of interprofessional team members and (2) creating an NAS specialized unit. Necessary processes of care included (1) prioritizing early involvement of interprofessional team members, (2) emphasizing nonjudgmental incorporation of previous experience with addiction, (3) establishing clear roles and expectations, and (4) maintaining transparency with social services. Lastly, we identified 9 outcomes resulting from these identified structures and processes that are meaningful to care team members to assess the quality of care for infants with NAS. CONCLUSIONS: In this study, we identify important structures, processes of care, and meaningful outcomes to enhance and evaluate TBC for infants with NAS. Hospitals that adopt and implement these structures and processes have the potential to improve the quality of care for infants, caregivers, and providers who care for these infants.

Effects of polysubstance exposure on neonatal outcomes for infants with intrauterine opioid exposure.

OBJECTIVE: Quantify the effect of prenatal polysubstance exposure on neonatal outcomes compared to methadone exposure alone. STUDY DESIGN: This retrospective cohort study compared infants with methadone-only exposure to methadone with additional psychoactive substances. Outcomes included time to maximum Finnegan scores, proportion requiring scheduled morphine, and length of stay (LOS). RESULTS: We identified 323 subjects. The median time to maximum Finnegan score was 38.0 h with 94% peaking within 96 h. Forty-five percent of methadone-only infants were started on scheduled morphine compared to 54% of polysubstance infants (p = 0.10). LOS for polysubstance-exposed infants was 1.30 times longer than infants with methadone-only exposure (95% confidence interval: 1.05, 1.60). CONCLUSIONS: Exposure to methadone with additional psychoactive substances is associated with longer LOS, but not postnatal morphine use or peak withdrawal symptoms. Most infants experience peak withdrawal symptoms within 4 days and may not benefit from longer observation.

Improving Care for Infants With Neonatal Abstinence Syndrome: A Multicenter, Community Hospital-Based Study.

BACKGROUND: For infants with neonatal abstinence syndrome (NAS) in children's hospitals, treatment protocols emphasizing nonpharmacologic care have revealed improved hospital outcomes. We sought to improve NAS care within the community hospital setting through the implementation of an Eat, Sleep, Console (ESC) protocol. METHODS: Using a multidisciplinary quality improvement approach, we implemented an ESC protocol at 2 community hospitals. Primary outcomes were to decrease length of stay (LOS) by 20% and decrease scheduled morphine use to <20%. Balancing measures included transfer to a higher level of care and unplanned 30-day readmissions. Data were extracted over 2 years, from 2017 through 2018. Interventions included an emphasis on nonpharmacologic care, the initiation of 1-time morphine dosing, flexible weaning schedules for infants on morphine, and the use of ESC scoring. Data were analyzed by using statistical process control. RESULTS: A total of 304 NAS patients were admitted from January 2017 to December 2018, with 155 during the postintervention period. After implementation, mean LOS decreased from 9.0 to 6.2 days, and morphine use decreased from 57% to 23%, both with special cause variation. There were 2 unplanned readmissions in the postintervention period compared with 1 preintervention and no transfers to higher level of care in either period. CONCLUSIONS: Implementation of a nonpharmacologic care protocol within 2 community hospitals led to significant and sustained improvement in LOS and morphine exposure without compromising safety. In this study, we illustrate that evidence-based practice can be successfully implemented and sustained within community hospitals treating infants with NAS.

Growth hormone perturbations in fibromyalgia: a review.

OBJECTIVE: Fibromyalgia (FM) is a syndrome characterized by chronic widespread pain, fatigue, disrupted sleep, depression, and physical deconditioning. In this article, we review the literature on the normal activity of the hypothalamic-pituitary-growth hormone-insulin-like growth factor-1 (HP-GH-IGF-1) axis and its perturbations in FM subjects. METHODS: Studies included in this review were accessed through an English language search of Cochrane Collaboration Reviews. Keyword MeSH terms included "fibromyalgia," "growth hormone" (GH), or "insulin-like growth factor-1" (IGF-1). RESULTS: Twenty-six studies enrolling 2006 subjects were reviewed. Overall, low levels of IGF-1 were found in a subgroup of subjects. Growth hormone stimulation tests often revealed a suboptimal response, which did not always correlate with IGF-1 levels. No consistent defects in pituitary function were found. Of the 3 randomized placebo controlled studies, only 9 months of daily injectable recombinant GH reduced FM symptoms and normalized IGF-1. CONCLUSIONS: These studies suggest that pituitary function is normal in FM and that reported changes in the HP-GH-IGF-1 axis are most likely hypothalamic in origin. The therapeutic efficacy of supplemental GH therapy in FM requires further study before any solid recommendations can be made.

An RNAi-Based Candidate Screen for Modifiers of the CHD1 Chromatin Remodeler and Assembly Factor in Drosophila melanogaster.

The conserved chromatin remodeling and assembly factor CHD1 (chromodomains, helicase, DNA-binding domain) is present at active genes where it participates in histone turnover and recycling during transcription. In order to gain a more complete understanding of the mechanism of action of CHD1 during development, we created a novel genetic assay in Drosophila melanogaster to evaluate potential functional interactions between CHD1 and other chromatin factors. We found that overexpression of CHD1 results in defects in wing development and utilized this fully penetrant and reliable phenotype to conduct a small-scale RNAi-based candidate screen to identify genes that functionally interact with chd1 in vivo. Our results indicate that CHD1 may act in opposition to other remodeling factors, including INO80, and that the recruitment of CHD1 to active genes by RTF1 is conserved in flies.

Six new loci associated with body mass index highlight a neuronal influence on body weight regulation.

Common variants at only two loci, FTO and MC4R, have been reproducibly associated with body mass index (BMI) in humans. To identify additional loci, we conducted meta-analysis of 15 genome-wide association studies for BMI (n > 32,000) and followed up top signals in 14 additional cohorts (n > 59,000). We strongly confirm FTO and MC4R and identify six additional loci (P < 5 x 10(-8)): TMEM18, KCTD15, GNPDA2, SH2B1, MTCH2 and NEGR1 (where a 45-kb deletion polymorphism is a candidate causal variant). Several of the likely causal genes are highly expressed or known to act in the central nervous system (CNS), emphasizing, as in rare monogenic forms of obesity, the role of the CNS in predisposition to obesity.

Meta-analysis of genome-wide association data and large-scale replication identifies additional susceptibility loci for type 2 diabetes.

Genome-wide association (GWA) studies have identified multiple loci at which common variants modestly but reproducibly influence risk of type 2 diabetes (T2D). Established associations to common and rare variants explain only a small proportion of the heritability of T2D. As previously published analyses had limited power to identify variants with modest effects, we carried out meta-analysis of three T2D GWA scans comprising 10,128 individuals of European descent and approximately 2.2 million SNPs (directly genotyped and imputed), followed by replication testing in an independent sample with an effective sample size of up to 53,975. We detected at least six previously unknown loci with robust evidence for association, including the JAZF1 (P = 5.0 x 10(-14)), CDC123-CAMK1D (P = 1.2 x 10(-10)), TSPAN8-LGR5 (P = 1.1 x 10(-9)), THADA (P = 1.1 x 10(-9)), ADAMTS9 (P = 1.2 x 10(-8)) and NOTCH2 (P = 4.1 x 10(-8)) gene regions. Our results illustrate the value of large discovery and follow-up samples for gaining further insights into the inherited basis of T2D.