Data are limited on the impact of methicillin-resistant Staphylococcus aureus (MRSA) on morbidity and mortality among very low birth weight (VLBW) infants with S aureus (SA) bacteremia and/or meningitis (B/M).
Neonatal data for VLBW infants (birth weight 401–1500 g) born January 1, 2006, to December 31, 2008, who received care at centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network were collected prospectively. Early-onset (≤72 hours after birth) and late-onset (>72 hours) infections were defined by blood or cerebrospinal fluid cultures and antibiotic treatment of ≥5 days (or death <5 days with intent to treat). Outcomes were compared for infants with MRSA versus methicillin-susceptible S aureus (MSSA) B/M.
Of 8444 infants who survived >3 days, 316 (3.7%) had SA B/M. Eighty-eight had MRSA (1% of all infants, 28% of infants with SA); 228 had MSSA (2.7% of all infants, 72% of infants with SA). No infant had both MRSA and MSSA B/M. Ninety-nine percent of MRSA infections were late-onset. The percent of infants with MRSA varied by center (P < .001) with 9 of 20 centers reporting no cases. Need for mechanical ventilation, diagnosis of respiratory distress syndrome, necrotizing enterocolitis, and other morbidities did not differ between infants with MRSA and MSSA. Mortality was high with both MRSA (23 of 88, 26%) and MSSA (55 of 228, 24%).
Few VLBW infants had SA B/M. The 1% with MRSA had morbidity and mortality rates similar to infants with MSSA. Practices should provide equal focus on prevention and management of both MRSA and MSSA infections among VLBW infants.
Staphylococcus aureus; methicillin resistant; infant; newborn
Extended duty hours for residents are associated with negative consequences. Strategies to accommodate duty hour restrictions may also have unintended impacts. To eliminate extended duty hours and potentially lessen these impacts, we developed a senior resident rotation bundle that integrates a night float system, educational sessions on sleep hygiene, an electronic handover tool, and a simulation-based medical education curriculum. The aim of this study was to assess internal medicine residents’ perceptions of the impact of the bundle on three domains: the senior residents’ wellness, ability to deliver quality health care, and medical education experience.
This prospective study compared eligible residents’ experiences (N = 67) before and after a six-month trial of the bundle at a training program in western Canada. Data was collected using an on-line survey. Pre- and post-intervention scores for the final sample (N = 50) were presented as means and compared using the t-test for paired samples.
Participants felt that most aspects of the three domains were unaffected by the introduction of the bundle. Four improved and two worsened perception shifts emerged post-intervention: less exposure to personal harm, reduced potential for medical error, more successful teaching, fewer disruptions to other rotations, increased conflicting role demands and less staff physician supervision.
The rotation bundle integrates components that potentially ease some of the perceived negative consequences of night float rotations and duty hour restrictions. Future areas of study should include objective measures of the three domains to validate our study participants’ perceptions.
Studies have demonstrated a higher risk of adverse outcomes among infants born or admitted during off-hours, as compared to office hours, leading to questions about quality of care provide during off-hours (weekend, evening or night). We aim to determine the relationship between off-hours delivery and adverse perinatal outcomes for subgroups of hospital births.
This retrospective cohort study was based on data from the Netherlands Perinatal Registry, a countrywide registry that covers 99% of all hospital births in the Netherlands. Data of 449,714 infants, born at 28 completed weeks or later, in the period 2003 through 2007 were used. Infants with a high a priori risk of morbidity or mortality were excluded. Outcome measures were intrapartum and early neonatal mortality, a low Apgar score (5 minute score of 0–6), and a composite adverse perinatal outcome measure (mortality, low Apgar score, severe birth trauma, admission to a neonatal intensive care unit).
Evening and night-time deliveries that involved induction or augmentation of labour, or an emergency caesarean section, were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Weekend deliveries were not associated with an increased risk when compared to weekday deliveries. It was estimated that each year, between 126 and 141 cases with an adverse perinatal outcomes could be attributed to this evening and night effect. Of these, 21 (15-16%) are intrapartum or early neonatal death. Among the 3100 infants in the study population who experience an adverse outcome each year, death accounted for only 5% (165) of these outcomes.
This study shows that for infants whose mothers require obstetric interventions during labour and delivery, birth in the evening or at night, are at an increased risk of an adverse perinatal outcomes.
Time of birth; Night; Weekend; Delivery; Perinatal mortality; Perinatal morbidity; Hospital care; Quality of health care
In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of regulations that mandated a reduction in the number of hours that medical residents can work. These requirements have generated controversy among medical educators, with some expressing concern that reducing resident hours may limit clinical exposure and competency, particularly in surgical specialties.
This study examines the impact of duty hour restrictions on resident operative experience in residents in 2 surgical subspecialties since the implementation of the ACGME duty hour limits.
We examined operative log data for vascular surgery and pediatric surgery, using the academic year immediately preceding the duty hour restrictions, 2002 to 2003, as a baseline for comparison to subsequent academic years through 2006 to 2007 for vascular surgery and 2007 to 2008 for pediatric surgery.
Graduating fellows in pediatric surgery showed no change in their total operative volume following duty hour restrictions. The pediatric-defined category of neonate procedures showed an increase following duty hour restrictions. Graduating fellows in vascular surgery showed an increase in total major procedures as surgeon. The vascular-defined categories of endovascular-diagnostic, endovascular-therapeutic, and endovascular-graft procedures also increased.
The reduction of duty hours has not resulted in a decrease in operative volume as some have predicted. Operative volume in pediatric surgery remained mainly unchanged, whereas operative volume in vascular surgery increased. We explore possible explanations for the observed findings.
Individuals with Down syndrome (DS) are at increased risk of several morbidities with lifelong health consequences. Little is known about mortality or morbidity risks in early infancy among very-low-birth-weight (VLBW) infants with DS. Our objective was to compare survival and neonatal morbidities between VLBW infants with DS and VLBW infants with other non-DS chromosomal anomalies, other non-chromosomal birth defects, and VLBW infants without major birth defects.
Data were collected prospectively for infants weighing 401-1500 grams born and/or cared for at one of the study centers participating in the NICHD Neonatal Research Network from 1994 through 2008. Risk of death and morbidities including patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), late onset sepsis (LOS), retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD), were compared between VLBW infants with DS and infants in the other groups.
Infants with DS were at increased risk of death (adjusted relative risk [RR] 2.47, 95% confidence interval [CI] 2.00-3.07), PDA, NEC, LOS, and BPD relative to infants with no birth defects. Decreased risk of death (RR 0.40, 95% CI 0.31-0.52) and increased risks of NEC and LOS were observed when comparing infants with DS to infants with other non-DS chromosomal anomalies. Relative to infants with non-chromosomal birth defects, infants with DS were at increased risk of PDA and NEC.
The increased risk of morbidities among VLBW infants with DS provides useful information for counseling parents and for caretakers in anticipating the need for enhanced surveillance for prevention of these morbidities.
neonatal mortality; neonatal morbidity; preterm infants; Down syndrome; trisomy 21
The restriction of the resident physician work week to 80 hours has had dramatic affects on resident education and life-style. While effects on mood, psychological distress, and burn-out have been studied, the resultant changes in tangible quality of life have received little attention. birth rate was considered a measurable, relevant outcome. The resident marital and parental status by duty month was collected from a single orthopaedic surgical residency program for the four academic years preceding and following the implementation of the 80-hour work week. the number of births to residents during these periods were also tallied. The relative prevalence of positive marital status changed very little between residents in the two time durations from 66 to 71 percent, but parental status increased from 27 to 43 percent. The number of births per married resident duty year also increased from 0.23 pre-restrictions to 0.32 post-restrictions. While the individual decisions involved in generating these observed changes are complex and difficult to entirely decipher, it is thought that an increased perception of life-control within the work-hour restrictions may have prompted the dramatic changes in birth rate among resident families.
Background and Purpose
Stroke requires consistent care, but there is concern over the "weekend effect", whereby a weekend admission results in a poor outcome. Our aim was to determine the impact of weekend admission on clinical outcomes in patients with acute ischemic stroke in Korea.
The outcomes of patients admitted on weekdays and weekends were compared by analyzing data from a prospective outcome registry enrolling 1247 consecutive patients with acute ischemic stroke admitted to four neurology training hospitals in South Korea between September 2004 and August 2005. The primary outcome was a poor functional outcome at 3 months, defined as modified Rankin Scale (mRS) of 3-6. Secondary outcomes were 3-month mortality, use of thrombolysis, complication rate, and length of hospitalization. Shift analysis was also performed to compare overall mRS distributions.
On weekends, 334 (26.8%) patients were admitted. Baseline characteristics were comparable between the weekday and weekend groups except for more history of heart disease and shorter admission time in weekend group. Univariate analysis revealed poor functional outcome at 3 months, 3-month mortality, complication rate, and length of hospitalization did not differ between the two groups. In addition, overall mRS distributions were comparable (p=0.865). After adjusting for baseline factors and stroke severity, weekend admission was not associated with poor functional outcome at 3 months (adjusted odds ratio, 1.05; 95% CI, 0.74-1.50). Furthermore, none of secondary endpoints differed between the two groups in multivariate analysis.
Weekend admission was not associated with poor functional outcome than weekday admission in patients with acute ischemic stroke in this study. The putative weekend effect should be explored further by considering a wider range of hospital settings and hemorrhagic stroke.
weekend effect; weekend admission; ischemic stroke
Higher risks of stillbirth or early neonatal death, or both, have been reported from several countries for births on weekend days. It is unclear whether such higher risks have persisted in recent years. We investigated weekend-associated risks of stillbirth and early neonatal death in most Canadian provinces.
We studied all 3 239 972 births recorded in Canada, excluding Ontario, between 1985 and 1998. The main outcome measures were the relative risks (RRs) of stillbirth and early neonatal death for infants born on weekends versus weekdays.
The proportion of births on weekend days was 24% lower than the proportion on weekdays. Infants born on weekend days had slightly but significantly elevated risks of stillbirth (RR 1.06, 95% confidence interval [CI] 1.02–1.09) and early neonatal death (RR 1.11, 95% CI 1.07–1.16). However, the higher risks disappeared after adjustment for gestational age.
The crude risks of stillbirth and early neonatal death remained slightly higher for births on weekend days, but the excesses were much smaller than those reported from other countries.
In 2003, the Accreditation Council for Graduate Medical Education instituted common duty hour limits, and in 2008 the Institute of Medicine recommended additional limits on continuous duty hours. Using a night-float system is an accepted approach for adhering to duty hour mandates.
To determine the effect of an on-site night-float attending physician on resident education and patient care.
Night-float residents and daytime ward residents were surveyed at the end of their rotation about the impact of an on-site night-float attending physician on education and quality of patient care. Responses were provided on a 5-point Likert scale ranging from 1, strongly agree, to 5, strongly disagree.
Overall, 92 of the 140 distributed surveys were completed (66% response rate). Night-float residents found the night-float attending physician to be helpful with cross-cover issues (mean = 2.00), initial history and physical examination (mean = 1.56), choosing appropriate diagnostic tests (mean = 1.79), developing a treatment plan (mean = 1.74), and improving overall patient care (mean = 1.91). Daytime ward residents were very satisfied with the quality of the admission workups (mean = 1.78), tests and diagnostic procedures (mean = 1.76), and initial treatment plan (mean = 1.62) provided by the night-float service.
A night-float system that includes on-site attending physician supervision can provide a valuable opportunity for resident education and may help improve the quality of patient care.
OBJECTIVE: To measure the effect of duty periods no longer than 16 hours on patient care and resident education.
PATIENTS AND METHODS: As part of our Educational Innovations Project, we piloted a novel resident schedule for an inpatient service that eliminated shifts longer than 16 hours without increased staffing or decreased patient admissions on 2 gastroenterology services from August 29 to November 27, 2009. Patient care variables were obtained through medical record review. Resident well-being and educational variables were collected by weekly surveys, end of rotation evaluations, and an electronic card-swipe system.
RESULTS: Patient care metrics, including 30-day mortality, 30-day readmission rate, and length of stay, were unchanged for the 196 patient care episodes in the 5-week intervention month compared with the 274 episodes in the 8 weeks of control months. However, residents felt less prepared to manage cross-cover of patients (P=.006). There was a nonsignificant trend toward decreased perception of quality of education and balance of personal and professional life during the intervention month. Residents reported working fewer weekly hours overall during the intervention (64.3 vs 68.9 hours; P=.40), but they had significantly more episodes with fewer than 10 hours off between shifts (24 vs 2 episodes; P=.004).
CONCLUSION: Inpatient hospital services can be staffed with residents working shifts less than 16 hours without additional residents. However, cross-cover of care, quality of education, and time off between shifts may be adversely affected.
The authors found that inpatient hospital services can be staffed with residents working shifts that are less than 16 hours without additional residents. However, cross-cover of care, quality of education, and time off between shifts may be adversely affected.
Although medical care for very-low-birth-weight (VLBW) infants has improved over time, it is unclear how this has affected mortality and morbidity. To characterize these trends, a network database was analyzed.
This is a cohort study of VLBW infants born from 2003 through 2008.
Over the 6-y period, 19,344 infants were registered and analyzed. Crude mortality rates among the infants at discharge decreased significantly (from 10.8 to 8.7%) during the study period. The greatest improvement in mortality was observed among infants with birth weights between 501 and 750 g (25.6–17.7 %). The odds ratio (OR) of mortality over year adjusted for potential confounders by a logistic regression model was 0.94 (95% confidence interval 0.92–0.97). Significant increases were observed in some morbidities, including symptomatic patent ductus arteriosus with an OR of 1.11 (1.09–1.13); late-onset adrenal insufficiency, 1.21 (1.17–1.26); and necrotizing enterocolitis/intestinal perforation, 1.10 (1.01–1.12). However, the severe form of intraventricular hemorrhage, with an OR of 0.98 (0.92–0.99), decreased significantly. Risk-adjusted trends in other morbidities showed no significant change.
Mortality of VLBW infants decreased significantly over the 6-y study period. Decreasing morbidity is essential for further improvement in the outcomes in VLBW infants.
In December 2008 the Institute of Medicine (IOM) released a report recommending limits on resident hours that are considerably more restrictive than the current Accreditation Council for Graduate Medical Education duty hour standards.
In March 2009, a large pediatric residency program implemented a 1-month trial of a schedule and team structure fully congruent with the IOM recommendations to study the implications of such a schedule.
Comparison of the interns' experience in the trialed intervention schedule was made to interns working a traditional schedule with every fourth night call.
The residents on the intervention schedule averaged 7.8 hours of sleep per 24-hour period compared to 7.6 hours for interns in a traditional schedule. Participation in bedside rounds and formal didactic conferences was decreased in the intervention schedule. Several factors contributed to increased perceived work intensity for interns in the intervention schedule. Redistribution of work during busy shifts altered the role of senior residents and attending physicians which may have a negative effect on senior residents' ability to develop skills as supervisors and educators.
The trial implementation suggests it is possible to implement the proposed duty hour limits in a pediatric residency, but it would require a significant increase in the resident workforce (at least 25% and possibly 50%) to care for the same number of patients. Furthermore, the education model would need to undergo significant changes. Further trials of the IOM recommendations are needed prior to widespread implementation in order to learn what works best and causes the least harm, disruption, and unnecessary cost to the system.
To assess the impact of time of birth on infant mortality and early neonatal mortality in full term and preterm births.
Analysis of data from the Swedish birth register, 1973-95.
2 102 324 spontaneous live births of infants without congenital malformation.
Absolute and relative risk of infant mortality, early neonatal mortality, and early neonatal mortality related to asphyxia.
Infant mortality, early neonatal mortality, and early neonatal mortality related to asphyxia were higher in infants who were born during the night (9 pm to 9 am) compared with those born during the day for 1973-9, 1980-9, and 1990-5. The difference was more dramatic for preterm infants. The largest difference was observed during 1990-5, when there was a 30% increase in early neonatal mortality (relative risk 1.31, 95% confidence interval 1.10 to 1.57) and a 70% increase in early neonatal mortality related to asphyxia (1.70, 1.22 to 2.38) in preterm infants born during the night compared with rates for preterm infants born during the day. A detailed analysis over 24 hours revealed two “high risk” periods: between 5 pm and 1 am and around 9 am.
Infants born during the night have a greater risk of infant and early neonatal mortality and early neonatal mortality related to asphyxia than those born during the day. There has been no improvement over the past two decades. The problem is more serious for preterm births and was even worse in the 1990s. Shift changes and the hours immediately after such changes are high risk periods for neonatal care.
What is already known on this topicInfants born at night have a greater risk of early neonatal mortality and early neonatal mortality related to asphyxia than those born during the dayThe causes are unclear but may be related to insufficient or less experienced staff or excess workload during the nightWhat this study addsIn Sweden the relative risks of infant and early neonatal mortality and mortality related to asphyxia for infants born during the night compared with during the day did not diminish during 1973-95, are greater for preterm infants, and were greater in the 1990sThere are two “high risk” periods for early neonatal mortality: 5 pm to 1 am and around 9 amThe exact reasons are unclear but better vigilance and an improvement in shift changes may be required to improve neonatal health care further
Delayed cord clamping may be beneficial in very preterm and low birth weight infants.
A randomized unmasked controlled trial
The study was performed in three centers of the NICHD Neonatal Research Network
Delayed cord clamping in very preterm and very low birth weight infants will result in an increase in hematocrit at 4 hours of age.
Infants with a gestational age of 24-28 weeks were randomized into early (< 10 seconds) or delayed (30-45 seconds) cord clamping. The primary outcome was venous hematocrit at 4 hours of age. Secondary outcomes included delivery room management, selected neonatal morbidities and the need for blood transfusion during the infants’ hospital stay.
Thirty three infants were randomized: 17 to the immediate cord clamping (ICC, cord clamped at 7.9 ± 5.2 seconds, m±SD) and 16 to the delayed cord clamping (DCC, cord clamped at 35.2 ± 10.1 seconds) group. The hematocrit was higher in the DCC group (45 ± 8 versus 40 ± 5%, p<0.05). The frequency of events during delivery room resuscitation was almost identical between the two groups. There was no difference in hourly mean arterial blood pressure during the first 12 hours of life, there was a trend in the difference in the incidence of selected neonatal morbidities, hematocrit at 2, 4 and 6 weeks as well as the need for transfusion, but none of the differences was statistically significant
A higher hematocrit is achieved by delayed cord clamping in very low birth weight infants suggesting effective placental transfusion.
The objective of this study was to determine the (1) incidence of short bowel syndrome in very low birth weight (<1500 g) infants, (2) associated morbidity and mortality during initial hospitalization, and (3) impact on short-term growth and nutrition in extremely low birth weight (<1000 g) infants.
Infants who were born from January 1, 2002, through June 30, 2005, and enrolled in the National Institute of Child Health and Human Development Neonatal Research Network were studied. Risk factors for developing short bowel syndrome as a result of partial bowel resection (surgical short bowel syndrome) and outcomes were evaluated for all neonates until hospital discharge, death, or 120 days. Extremely low birth weight survivors were further evaluated at 18 to 22 months’ corrected age for feeding methods and growth.
The incidence of surgical short bowel syndrome in this cohort of 12 316 very low birth weight infants was 0.7%. Necrotizing enterocolitis was the most common diagnosis associated with surgical short bowel syndrome. More very low birth weight infants with short bowel syndrome (20%) died during initial hospitalization than those without necrotizing enterocolitis or short bowel syndrome (12%) but fewer than the infants with surgical necrotizing enterocolitis without short bowel syndrome (53%). Among 5657 extremely low birth weight infants, the incidence of surgical short bowel syndrome was 1.1%. At 18 to 22 months, extremely low birth weight infants with short bowel syndrome were more likely to still require tube feeding (33%) and to have been rehospitalized (79%). Moreover, these infants had growth delay with shorter lengths and smaller head circumferences than infants without necrotizing enterocolitis or short bowel syndrome.
Short bowel syndrome is rare in neonates but has a high mortality rate. At 18 to 22 months’ corrected age, extremely low birth weight infants with short bowel syndrome were more likely to have growth failure than infants without short bowel syndrome.
short bowel syndrome; preterm; necrotizing enterocolitis; nutrition
The ACGME-released revisions to the 2003 duty hour standards.
To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.
Medline (1989–May 2010), Embase (1989–June 2010), bibliographies, pertinent reviews, and meeting abstracts.
We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.
One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.
Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I2 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.
Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.
Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1657-1) contains supplementary material, which is available to authorized users.
Resident duty-hour regulations potentially shift workload from resident to attending physicians. We sought to understand how current or future regulatory changes might impact safety in academic pediatric and neonatal intensive care units (ICUs).
US academic pediatric and neonatal ICUs
Attending pediatric and neonatal intensivists
We evaluated perceptions on four ICU safety-related risk measures potentially affected by current duty-hour regulations: 1) Attending physician and resident fatigue, 2) Attending physician work-load, 3) Errors (self-reported rates by attending physicians or perceived resident error rates), and 4) Safety culture. We also evaluated perceptions of how these risks would change with further duty hour restrictions.
Measurements and Main Results
We administered our survey between February and April 2010 to 688 eligible physicians, of which 360 (52.3%) responded. Most believed that resident error rates were unchanged or worse (91.9%) and safety culture was unchanged or worse (84.4%) with current duty-hour regulations. Of respondents, 61.9% believed their own work-hours providing direct patient care increased and 55.8% believed they were more fatigued while providing direct patient care. Most (85.3%) perceived no increase in their own error rates currently, but in the scenario of further reduction in resident duty-hours, over half (53.3%) believed that safety culture would worsen and a significant proportion (40.3%) believed that their own error rates would increase.
Pediatric intensivists do not perceive improved patient safety from current resident duty hour restrictions. Policies to further restrict resident duty hours should consider unintended consequences of worsening certain aspects of ICU safety.
Resident duty hours; graduate medical education; Patient Safety; Intensive Care; Pediatrics; Medical Errors
Hyperglycemia often occurs in premature, very low birthweight infants (VLBW) due to immaturity of endogenous regulatory systems and the stress of their condition. Hyperglycemia in neonates has been linked to increased morbidities and mortality and occurs at increasing rates with decreasing birthweight. In this cohort, the emerging use of insulin to manage hyperglycemia has carried a significant risk of hypoglycemia. The efficacy of blood glucose control using a computer metabolic system model to determine insulin infusion rates was assessed in very-low-birth-weight infants.
Initial short-term 24-hour trials were performed on 8 VLBW infants with hyperglycemia followed by long-term trials of several days performed on 22 infants. Median birthweight was 745 g and 760 g for short-term and long-term trial infants, and median gestational age at birth was 25.6 and 25.4 weeks respectively. Blood glucose control is compared to 21 retrospective patients from the same unit who received insulin infusions determined by sliding scales and clinician intuition. This study was approved by the Upper South A Regional Ethics Committee, New Zealand (ClinicalTrials.gov registration NCT01419873).
Reduction in hyperglycemia towards the target glucose band was achieved safely in all cases during the short-term trials with no hypoglycemic episodes. Lower median blood glucose concentration was achieved during clinical implementation at 6.6 mmol/L (IQR: 5.5 – 8.2 mmol/L, 1,003 measurements), compared to 8.0 mmol/L achieved in similar infants previously (p < 0.01). No significant difference in incidence of hypoglycemia during long-term trials was observed (0.25% vs 0.25%, p = 0.51). Percentage of blood glucose within the 4.0 – 8.0 mmol/L range was increased by 41% compared to the retrospective cohort (68.4% vs 48.4%, p < 0.01).
A computer model that accurately captures the dynamics of neonatal metabolism can provide safe and effective blood glucose control without increasing hypoglycemia.
ClinicalTrials.gov registration NCT01419873
Hyperglycemia; Premature birth; Insulin; Control; Insulin sensitivity
In anticipation of the 2011 ACGME duty hour requirements, we redesigned our internal medicine resident ward experience. Our previous ward structure included a maximum 30-hour duty period for postgraduate year-1 (PGY-1) residents. In the redesigned ward structure, PGY-1 residents had a maximum 18-hour duty period.
We evaluated resident conference attendance and duty hour violations before and after implementation of our new ward redesign. We administered a satisfaction survey to residents and faculty 6 months after implementation of the new ward redesign.
Before implementation of the ward redesign, 30-hour continuous and 80-h/wk duty violations were each 2/year, and violations of the 10-hour rest between duty periods were 10/year for 74 residents. After implementation of the ward redesign, there were no 30-hour continuous or 80-h/wk duty violations, but violations of the 10-hour rest between duty periods more than doubled (26/year for 75 residents). Duty hours were reported by different mechanisms for the 2 periods. Conference attendance improved. Resident versus faculty satisfaction scores were similar. Both groups judged overall professional satisfaction as slightly worse after implementation.
Our ward rotation redesign eliminated 30-hour continuous and 80-h/wk duty violations as well as improved conference attendance. These benefits occurred at the cost of more faculty hires, decreased resident elective time, and slightly worse postimplementation satisfaction scores.
The heptavalent pneumococcal-CRM197 conjugate vaccine (PCV-7) has been incompletely studied in very-low-birth-weight (VLBW, ≤1500 grams) infants.
To assess PCV-7 immunogenicity in VLBW, premature infants. We hypothesized that the frequency of post-vaccine antibody concentrations ≥0.15 µg/mL would vary directly with birth weight.
This was a multi-center observational study. Infants 401–1500 grams birth weight and <32 0/7 weeks gestation, stratified by birth weight, were enrolled from 9 NICHD Neonatal Research Network centers. Infants received PCV-7 at 2, 4 and 6 months after birth and had blood drawn 4–6 weeks following the third dose. Antibodies against the 7 vaccine serotypes were measured by enzyme-linked immunosorbent assay.
Of 369 enrolled infants, 244 completed their primary vaccine series by 8 months and had serum obtained. Subjects were 27.8 ± 2.2 (mean ± standard deviation) weeks gestation and 1008 ± 282 grams birth weight. Twenty-six percent had bronchopulmonary dysplasia and 16% had received postnatal glucocorticoids. Infants 1001–1500 grams birth weight were more likely than those 401–1000 grams to achieve antibody concentrations ≥0.15 µg/mL against the least two immunogenic serotypes (6B: 96% v. 85%, P = 0.003 and 23F: 97% v. 88%, P = 0.009). In multiple logistic regression analysis, lower birth weight, postnatal glucocorticoid use, lower weight at blood draw and Caucasian race were each independently associated with antibody concentrations <0.35 µg/mL against serotypes 6B and/or 23F.
When compared with larger premature infants, infants weighing ≤1000 grams at birth have similar antibody responses to most, but not all, PCV-7 vaccine serotypes.
Infant, premature; infant, very low birth weight; pneumococcal vaccines; immunization; vaccines
Late onset neonatal septicaemia (LONS) is one of the major causes of morbidity and mortality in very low birth weight (VLBW) infants. The main objective of this study was to investigate the rate of LONS in the Neonatal Intensive Care Unit (NICU) of King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia over a three year period and compare it to international standards.
To determine the incidence of LONS, a retrospective study was undertaken and premature infants with a birth weight less than 1250 g were included, giving a total of 273 infants. Their bacterial profile and the antimicrobial susceptibility of the isolates were investigated, and the changes in trends over the study period studied.
91.5% of included infants (217/237) had 1 or more blood cultures obtained beyond the second day of life. 41% (98/237) of included infants had at least one episode of proven sepsis. The majority (71.4%) of first episode sepsis was caused by Gram-positive organisms. Coagulase negative Staphylococcus accounted for around 80% of all Gram-positive infections. Gram-negative pathogens accounted for 24.5% of the late onset infections while fungal organisms were responsible for 4%.
The rate of LONS was high and exceeded internationally reported rates in our tertiary care NICU. Gram-positive organisms continue to be major causative isolates. High priority should be placed on preventative steps to control nosocomial sepsis.
Very low birth weight infants; Sepsis; Epidemiology
To investigate the association between birth month/photoperiod and refraction in infancy.
722 children with refractions measured between 1 and 3 months were included in this analysis. Non-cycloplegic near retinoscopy was performed by three experienced optometrists over a 32 year period. Photoperiod hours were calculated as the mean daylight hours 30 days after each infant's birth and then grouped into quartiles between 9.12 and 15.25 hrs. Two classifications for birth season were considered: regular season (Spring: March-May, Summer: June-August, Fall: September-November, and Winter: December-February) and alternate season (Spring: February-April, Summer: May-July, Fall: August-October, and Winter: November-January).
The mean infant age was 2.11 +/− 0.55 months. The mean spherical equivalent refraction (SER) was 0.61 +/−1.56D. Children born in the photoperiod group with the most daylight hours had slightly lower refractions than those in the shortest photoperiod group (0.43D±1.60D vs. 0.87D±1.43D, p<0.05). In the longest photoperiod group the percentage of infants with SER<= −0.25D was significantly higher (51/179=28.49%) than in the shortest photoperiod group (31/177=17.51%) (p=0.02). Similar patterns were observed using the alternate season classification, with 1) lower mean SER in infants born in the summer vs. the winter and 2) a higher percentage of SER<= −0.25D in infants born in the summer vs. the winter. However, by regular seasons, the mean SERs were similar between summer and winter.
A small, statistically significant lower refraction was found in infants with the most vs. the least daylight soon after birth, suggesting that light might play a small role in the refractive error of newborns.
refractive error; infants; birth season; photoperiod; myopia
We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their management on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.
Acute coronary syndrome; Weekend; Weekday; Mortality; Admission.
In December 2008, the Institute of Medicine (IOM) released the report of a consensus committee recommending added limits on resident duty hours.
Perceptions of interns participating in a 1-month trial implementation of the IOM-recommended duty hour limits in one large pediatric residency program during March 2009 were aggregated.
Interns experienced benefits from the shift-based schedule, including reduced hours and more nights at home. These were accompanied by shortcomings of the new schedule, most prominently increased intensity during the hours worked, weaknesses in sign-outs and handing off of tasks, and inability to know and “own” all patients on the interns' team. The experiment also changed the role and the level of engagement expected from attending physicians.
The trial implementation of the IOM-recommended limits highlighted that to adapt to additional reduction in hours, residency education needs a significant culture change, including better sign-outs, improved organization of bedside and didactic education, and attention to the added work intensity of a team-based model with daily admissions. Ultimately this may require an adjustment in residents' workload and different expectations and models of support from attending physicians.
Whereas most resident fathers are able to spend more time with their children on weekends than on weekdays, many fathers work on the weekends spending less time with their children on these days. There are conflicting findings about whether fathers are able to make up for lost weekend time on weekdays. Using unique features of the United Kingdom’s National Survey of Time Use 2000 (UKTUS) I examine the impact of fathers’ weekend work on the time fathers spend with their children, family, and partners (N = 595 fathers). I find that weekend work is common among fathers and is associated with less time with children, families, and partners. Fathers do not recover lost time with children on weekdays, largely because weekend work is a symptom of overwork. Findings also reveal that even if fathers had compensatory time, they are unlikely to recover lost time spent as a family or couple.
Fathers; paid work; time use; child care; work hours