Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs

To describe ventilation strategies used during extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure among level IV neonatal ICUs (NICUs). Design: Cross-sectional electronic survey. Setting: Email-based Research Electronic Data Capture survey. Patients: Neonates undergoing ECMO for respiratory failure at level IV NICUs. Interventions: A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children\u27s Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. Measurements and main results: Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16-20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9-10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10-15 (60%), and Fio2 22-30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6-7 (45%), PIP of 21-25 (55%), and tidal volume 5-5.9 mL/kg (50%). Conclusions: The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients

Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants

Background: Limited data suggest that higher hemoglobin thresholds for red-cell transfusions may reduce the risk of cognitive delay among extremely-low-birth-weight infants with anemia. Methods: We performed an open, multicenter trial in which infants with a birth weight of 1000 g or less and a gestational age between 22 weeks 0 days and 28 weeks 6 days were randomly assigned within 48 hours after delivery to receive red-cell transfusions at higher or lower hemoglobin thresholds until 36 weeks of postmenstrual age or discharge, whichever occurred first. The primary outcome was a composite of death or neurodevelopmental impairment (cognitive delay, cerebral palsy, or hearing or vision loss) at 22 to 26 months of age, corrected for prematurity. Results: A total of 1824 infants (mean birth weight, 756 g; mean gestational age, 25.9 weeks) underwent randomization. There was a between-group difference of 1.9 g per deciliter (19 g per liter) in the pretransfusion mean hemoglobin levels throughout the treatment period. Primary outcome data were available for 1692 infants (92.8%). Of 845 infants in the higher-threshold group, 423 (50.1%) died or survived with neurodevelopmental impairment, as compared with 422 of 847 infants (49.8%) in the lower-threshold group (relative risk adjusted for birth-weight stratum and center, 1.00; 95% confidence interval [CI], 0.92 to 1.10; P = 0.93). At 2 years, the higher- and lower-threshold groups had similar incidences of death (16.2% and 15.0%, respectively) and neurodevelopmental impairment (39.6% and 40.3%, respectively). At discharge from the hospital, the incidences of survival without severe complications were 28.5% and 30.9%, respectively. Serious adverse events occurred in 22.7% and 21.7%, respectively. Conclusions: In extremely-low-birth-weight infants, a higher hemoglobin threshold for red-cell transfusion did not improve survival without neurodevelopmental impairment at 22 to 26 months of age, corrected for prematurity

Safeguarding the polar regions from dangerous geoengineering: a critical assessment of proposed concepts and future prospects

Fossil-fuel burning is heating the planet with catastrophic consequences for its habitability and for the natural world on which our existence depends. Halting global warming requires rapid and deep decarbonization to “net zero” carbon dioxide (CO2) emissions, which needs to be achieved by 2050 if warming is to remain within the limits set out by the 2015 Paris Agreement. However, some scientists and engineers claim that a mid-century decarbonization target will not be reached, and they propose that we should focus on technological geoengineering “fixes” or “climate interventions” that could delay or mask some of the impacts of global warming. They often cite the need to slow warming in polar regions because they are experiencing rates of warming higher than the global average, with severe and irreversible projected consequences both locally (e.g., on fragile ecosystems) and globally (e.g., on sea level). Several geoengineering concepts exist for polar regions, but they have not been fully examined by the polar science community, nor integrated with an understanding of polar dynamics and responses. Here, we evaluate five of those polar geoengineering concepts and highlight the significant issues and risks relating to technological availability, logistical feasibility, cost, predictable adverse consequences, environmental damage, scalability (in space and time), governance, and ethics. According to our expert assessment, none of these geoengineering ideas pass scrutiny regarding their use in the coming decades. Instead, we find that the proposed concepts would be environmentally dangerous. It is clear to us that the assessed approaches are not feasible, and that further research into these techniques would not be an effective use of limited time and resources. It is vital that these ideas do not distract from the priority to reduce greenhouse gas (GHG) emissions or from the critical need to conduct fundamental research in the polar regions

Presumed Systemic Inflammatory Response Syndrome in the Pediatric Emergency Department.

OBJECTIVE: The aim of this study was to examine the incidence and outcomes of patients presenting with systemic inflammatory response syndrome (SIRS) in the pediatric emergency department (PED). METHODS: This was a descriptive, retrospective cohort study of all patients from birth to 18 years presenting to the PED of a single center on 16 days distributed over 1 year. The presence of presumed SIRS (pSIRS, defined as noncore temperature measurement and cell count when clinically indicated) and sepsis was determined for all study patients. Patients were followed up for 1 week. RESULTS: The incidence of pSIRS was 15.3% (216/1416). Suspected or proven infection was present in 37.1% (n = 525) of the study population and 76.4% (n = 165) with pSIRS, with no cases of severe sepsis or septic shock. Sensitivity and specificity of pSIRS for predicting infection were 31.4% (95% confidence interval [CI], 27.5%-35.6%) and 94.3% (95% CI, 92.5%-95.7%), respectively. Although patients with pSIRS had a relative risk of 2.4 (95% CI, 1.6-3.5; P \u3c 0.0001) for admission, 74% were discharged home with no subsequent PED visits. Of defined sepsis cases, 75% were discharged home without return. CONCLUSIONS: Presumed SIRS and sepsis are relatively common in the PED. Use of pSIRS to screen for sepsis risks missing infection, whereas using pSIRS in the current sepsis definition results in overinclusion of nonsevere illness

A novel data solution to analyse curriculum decolonisation – the case of Imperial College London Masters in Public Health

Analyses of reading lists by some UK Higher Education institutions in attempt to identify bias in curricula have found a prevalence of articles from the global north. However, previous studies have employed resource-intensive audit and data collection methods such as the authors or volunteers manually searching for and tagging individual reading list items by characteristic such as author country or place of publication. This can be prohibitive to repeating the study at different time periods or on large reading list data sets, which leads to a gap in evidence-based data to support and inform curriculum decolonisation. We describe a novel computational method applied to 568 articles, representing 3,166 authors from the Imperial College London Masters in Public Health (MPH) programme over two time periods (2017-18 and 2019-20). Using summary statistics, we found a shift in composite geographic distribution of reading lists sources across the two time periods studied and relate this to interventions to decolonise the curriculum at Imperial. Our approach to applying a computational method to produce data as evidence in decolonisation toolkits is discussed

A novel data solution to inform curriculum decolonisation: the case of the Imperial College London Masters of Public Health

AbstractThere is increasing interest within Higher Education Institutions (HEIs) to examine curricula for legacies of colonialism or empire that might result in a preponderance of references to research from the global north. Prior attempts to study reading lists for author geographies have employed resource-intensive audit and data collection methods based on manual searching and tagging individual reading list items by characteristics such as author country or place of publication. However, these manual methods are impractical for large reading lists with hundreds of citations that change over instances the course is taught. Laborious manual methods may explain why there is a lack of quantitative evidence to inform this debate and the understanding of geographic distribution of curricula. We describe a novel computational method applied to 568 articles, representing 3166 authors from the Imperial College London Masters in Public Health programme over two time periods (2017–18 and 2019–20). Described with summary statistics, we found a marginal shift away from global north-affiliated authors on the reading lists of one Masters course over two time periods and contextualise the role and limitations of the use of quantitative data in the decolonisation discourse. The method provides opportunities for educators to examine the distribution of course readings at pace and over time, serving as a useful point of departure to engage in decolonisation debates.</jats:p

A novel data solution to analyse curriculum decolonisation – the case of Imperial College London Masters in Public Health

Analyses of reading lists by some UK Higher Education institutions in attempt to identify bias in curricula have found a prevalence of articles from the global north. However, previous studies have employed resource-intensive audit and data collection methods such as the authors or volunteers manually searching for and tagging individual reading list items by characteristic such as author country or place of publication. This can be prohibitive to repeating the study at different time periods or on large reading list data sets, which leads to a gap in evidence-based data to support and inform curriculum decolonisation. We describe a novel computational method applied to 568 articles, representing 3,166 authors from the Imperial College London Masters in Public Health (MPH) programme over two time periods (2017-18 and 2019-20). Using summary statistics, we found a shift in composite geographic distribution of reading lists sources across the two time periods studied and relate this to interventions to decolonise the curriculum at Imperial. Our approach to applying a computational method to produce data as evidence in decolonisation toolkits is discussed.</p