Publications by authors named "Erika Edwards"

153 Publications

Early-Onset Sepsis Among Very Preterm Infants.

Pediatrics 2021 Sep 7. Epub 2021 Sep 7.

Department of Pediatrics, Larner College of Medicine.

Objectives: To determine the epidemiology and microbiology of early-onset sepsis (EOS) among very preterm infants using a nationally representative cohort from academic and community hospitals to inform empirical antibiotic guidance, highlight risk factors for infection, and aid in prognostication for infected infants.

Methods: Prospective observational study of very preterm infants born weighing 401 to 1500 g or at 22 to 29 weeks' gestational age from January 2018 to December 2019 in 753 Vermont Oxford Network centers. EOS was defined as a culture-confirmed bacterial infection of the blood or cerebrospinal fluid in the 3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without EOS.

Results: Of 84 333 included infants, 1139 had EOS for an incidence rate of 13.5 per 1000 very preterm births (99% confidence interval [CI] 12.5-14.6). (538 of 1158; 46.5%) and group B (218 of 1158; 18.8%) were the most common pathogens. Infected infants had longer lengths of stay (median 92 vs 66 days) and lower rates of survival (67.5% vs 90.4%; adjusted risk ratio 0.82 [95% CI 0.79-0.85]) and of survival without morbidity (26.1% vs 59.4%; adjusted risk ratio 0.66 [95% CI 0.60-0.72]).

Conclusions: In a nationally representative sample of very preterm infants with EOS from 2018 to 2019, approximately one-third of isolates were neither group B nor . Three-quarters of all infected infants either died or survived with a major medical morbidity. The profoundly negative impact of EOS on very preterm infants highlights the need for novel preventive strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2021-052456DOI Listing
September 2021

Follow-through care for high-risk infants during the COVID-19 pandemic: lessons learned from the Vermont Oxford Network.

J Perinatol 2021 Jul 27. Epub 2021 Jul 27.

University of Vermont Medical Center, Burlington, VT, USA.

Objective: The COVID-19 pandemic has altered the delivery of follow-up care for high-risk infants. We performed an audit to characterize programmatic responses in a quality improvement network.

Study Design: We audited 43 North American-based follow-up programs of the Vermont Oxford Network Extremely Low Birth Weight Follow-up Study Group in October, 2020. Our electronic survey included yes/no, agree/disagree, and free text response items.

Result: The response rate was 67.4%. Most programs altered capacity and the timing, frequency, or content of clinical assessments. Most perceived practice changes compromised their ability to ascertain infants' medical and developmental needs. There was a rapid uptake of telemedicine services. Despite challenges with implementation, many endorsed improved connectedness with families.

Conclusion: Programs adapted rapidly to meet the needs of high-risk infants during the pandemic. Clinical operations, assessment procedures, and quality metrics will also need to evolve. Quality improvement study group collaboratives are well-positioned to coordinate such work.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41372-021-01158-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314022PMC
July 2021

Quality of Care in US NICUs by Race and Ethnicity.

Pediatrics 2021 Aug 22;148(2). Epub 2021 Jul 22.

Vermont Oxford Network, Burlington, Vermont.

Background: Summary measures are used to quantify a hospital's quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States.

Methods: Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks' gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants.

Results: This prospective cohort included 169 400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average.

Conclusions: With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-037622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344358PMC
August 2021

Severity of Bronchopulmonary Dysplasia Among Very Preterm Infants in the United States.

Pediatrics 2021 Jul 2;148(1). Epub 2021 Jun 2.

Department of Pediatrics, The Robert Larner, M.D. College of Medicine.

Background And Objectives: The National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition.

Methods: Retrospective cohort study of infants born from 22 to 29 weeks' gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined.

Results: Among 24 896 infants, 2574 (10.3%) died before 36 weeks' postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks' PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks' gestation to 17.3% and 0.8% among infants born at 29 weeks' gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks' gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%-31.4%), surgically treated necrotizing enterocolitis (1.4%-17.1%), severe retinopathy of prematurity (1.2%-23.0%), and home oxygen therapy (2.0%-67.5%).

Conclusions: More than one-half of very preterm infants born in the United States died before 36 weeks' PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-030007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8290972PMC
July 2021

Trends in Retinopathy of Prematurity Screening and Treatment: 2008-2018.

Pediatrics 2021 Jun 11;147(6). Epub 2021 May 11.

Vermont Oxford Network, Burlington, Vermont; and.

Background And Objectives: Retinopathy of prematurity (ROP) is the leading avoidable and treatable cause of childhood blindness in the United States. The objective of this study was to evaluate trends of ROP screening, incidence, and treatment in US NICUs over the last 11 years.

Methods: Using standardized data submitted by NICUs from US Vermont Oxford Network member hospitals from 2008 to 2018 on very low birth weight infants hospitalized at the recommended age for ROP screening, we assessed trends in the proportion of eligible infants who received ROP screening, incidence, and treatment of ROP using logistic regression models.

Results: This study included 381 065 very low birth weight infants at 819 US NICUs participating in Vermont Oxford Network. Over time, more eligible infants received ROP screening (89% in 2008 to 91% in 2018, trend < .001). Among those screened, overall ROP (stages 1-5, 37% in 2008 to 32% in 2018), severe ROP (stages 3-5, 8% in 2008 to 6% in 2018), and retinal ablation (6% in 2008 to 2% in 2018) declined and anti-vascular endothelial growth factor injections (1% in 2012 to 2% in 2018) increased (all trend < .001).

Conclusions: Among US hospitals from 2008 to 2018, the proportion of ROP screening among infants hospitalized at the recommended age increased, less overall and severe ROP were reported, less retinal ablation was performed, and more anti-vascular endothelial growth factor treatment was used. Despite increased ROP screening over time, 10% of infants were not screened, representing an opportunity for improvement in health care delivery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-039966DOI Listing
June 2021

CAM photosynthesis in desert blooming Cistanthe of the Atacama, Chile.

Funct Plant Biol 2021 06;48(7):691-702

Smithsonian Tropical Research Institute, PO Box 0843-03092, Balboa, Ancon, Panama.

When plants of the Atacama desert undergo episodic blooms, among the most prominent are succulent-leaved Cistanthe (Montiaceae). We demonstrate that two Cistanthe species, the perennial Cistanthe sp. aff. crassifolia and the annual/biannual Cistanthe sp. aff. longiscapa, can exhibit net CO2 uptake and leaf acidification patterns typical of crassulacean acid metabolism (CAM). In C. sp. aff. crassifolia leaves, CAM expression was facultative. CAM-type nocturnal net CO2 uptake and acid accumulation occurred in drought-stressed but not in well-watered plants. By contrast, CAM expression in C. sp. aff. longiscapa was largely constitutive. Nocturnal acid accumulation was present in leaves of well-watered and in droughted plants. Following water-deficit stress, net nocturnal CO2 uptake was induced and the level of acid accumulated increased. Neither nocturnal CO2 uptake nor acid accumulation was reduced when the plants were re-watered. δ13C values of a further nine field-collected Cistanthe species are consistent with a contribution of CAM to their carbon pools. In the Portulacinae, a suborder with eight CAM-containing families, Cistanthe becomes the sixth genus with CAM within the family Montiaceae, and it is likely that the ancestor of all Portulacineae also possessed CAM photosynthesis. In the stochastic rainfall landscape of the Atacama, carbon uptake in the dark is a water-use efficient mechanism that increases the carbon pool available for seed production or dormancy. The next rain event may be years away.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1071/FP20305DOI Listing
June 2021

Following through: Interventions to improve long-term outcomes of preterm infants.

Semin Perinatol 2021 Jun 21;45(4):151414. Epub 2021 Mar 21.

Vermont Oxford Network, Burlington, VT, USA; Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA.

The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.semperi.2021.151414DOI Listing
June 2021

Developmental and biophysical determinants of grass leaf size worldwide.

Nature 2021 04 24;592(7853):242-247. Epub 2021 Mar 24.

Department of Ecology and Evolutionary Biology, University of California Los Angeles, Los Angeles, CA, USA.

One of the most notable ecological trends-described more than 2,300  years ago by Theophrastus-is the association of small leaves with dry and cold climates, which has recently been recognized for eudicotyledonous plants at a global scale. For eudicotyledons, this pattern has been attributed to the fact that small leaves have a thinner boundary layer that helps to avoid extreme leaf temperatures and their leaf development results in vein traits that improve water transport under cold or dry climates. However, the global distribution of leaf size and its adaptive basis have not been tested in the grasses, which represent a diverse lineage that is distinct in leaf morphology and that contributes 33% of terrestrial primary productivity (including the bulk of crop production). Here we demonstrate that grasses have shorter and narrower leaves under colder and drier climates worldwide. We show that small grass leaves have thermal advantages and vein development that contrast with those of eudicotyledons, but that also explain the abundance of small leaves in cold and dry climates. The worldwide distribution of leaf size in grasses exemplifies how biophysical and developmental processes result in convergence across major lineages in adaptation to climate globally, and highlights the importance of leaf size and venation architecture for grass performance in past, present and future ecosystems.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41586-021-03370-0DOI Listing
April 2021

The use of data in resource limited settings to improve quality of care.

Semin Fetal Neonatal Med 2021 Feb 3;26(1):101204. Epub 2021 Feb 3.

University of Vermont Larner College of Medicine, Department of Pediatrics, Burlington, VT, USA; Vermont Oxford Network, Burlington, VT, USA. Electronic address:

Quality improvement is driven by benchmarking between and within institutions over time and the collaborative improvement efforts that stem from these comparisons. Benchmarking requires systematic collection and use of standardized data. Low- and middle-income countries (LMIC) have great potential for improvements in newborn outcomes but serious obstacles to data collection, analysis, and implementation of robust improvement methodologies exist. We review the importance of data collection, internationally recommended neonatal metrics, selected methods of data collection, and reporting. The transformation from data collection to data use is illustrated by several select data system examples from LMIC. Key features include aims and measures important to neonatal team members, co-development with local providers, immediate access to data for review, and multidisciplinary team involvement. The future of neonatal care, use of data, and the trajectory to reach global neonatal improvement targets in resource-limited settings will be dependent on initiatives led by LMIC clinicians and experts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.siny.2021.101204DOI Listing
February 2021

Choosing wisely for the other 80%: What we need to know about the more mature newborn and NICU care.

Semin Perinatol 2021 Apr 23;45(3):151395. Epub 2021 Jan 23.

The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, NH, Lebanon.

Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns-infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns-infants of 34 or more weeks' gestation-account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.semperi.2021.151395DOI Listing
April 2021

Discharge Age and Weight for Very Preterm Infants: 2005-2018.

Pediatrics 2021 02;147(2)

Vermont Oxford Network, Burlington, Vermont.

Background: A complex set of medical, social, and financial factors underlie decisions to discharge very preterm infants. As care practices change, whether postmenstrual age and weight at discharge have changed is unknown.

Methods: Between 2005 and 2018, 824 US Vermont Oxford Network member hospitals reported 314 811 infants 24 to 29 weeks' gestational age at birth without major congenital abnormalities who survived to discharge from the hospital. Using quantile regression, adjusting for infant characteristics and complexity of hospital course, we estimated differences in median age, weight, and discharge weight score at discharge stratified by gestational age at birth and by NICU type.

Results: From 2005 to 2018, postmenstrual age at discharge increased an estimated 8 (compatibility interval [CI]: 8 to 9) days for all infants. For infants initially discharged from the hospital, discharge weight increased an estimated 316 (CI: 308 to 324) grams, and median discharge weight score increased an estimated 0.19 (CI: 0.18 to 0.20) standard units. Increases occurred within all birth gestational ages and across all NICU types. The proportion of infants discharged home from the hospital on human milk increased, and the proportions of infants discharged home from the hospital on oxygen or a cardiorespiratory monitor decreased.

Conclusions: Gestational age and weight at discharge increased steadily from 2005 to 2018 for survivors 24 to 29 weeks' gestation with undetermined causes, benefits, and costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-016006DOI Listing
February 2021

Lineage-based functional types: characterising functional diversity to enhance the representation of ecological behaviour in Land Surface Models.

New Phytol 2020 10 31;228(1):15-23. Epub 2020 Jul 31.

Forest Ecosystems and Society, Oregon State University, Corvallis, OR, 97331, USA.

Process-based vegetation models attempt to represent the wide range of trait variation in biomes by grouping ecologically similar species into plant functional types (PFTs). This approach has been successful in representing many aspects of plant physiology and biophysics but struggles to capture biogeographic history and ecological dynamics that determine biome boundaries and plant distributions. Grass-dominated ecosystems are broadly distributed across all vegetated continents and harbour large functional diversity, yet most Land Surface Models (LSMs) summarise grasses into two generic PFTs based primarily on differences between temperate C grasses and (sub)tropical C grasses. Incorporation of species-level trait variation is an active area of research to enhance the ecological realism of PFTs, which form the basis for vegetation processes and dynamics in LSMs. Using reported measurements, we developed grass functional trait values (physiological, structural, biochemical, anatomical, phenological, and disturbance-related) of dominant lineages to improve LSM representations. Our method is fundamentally different from previous efforts, as it uses phylogenetic relatedness to create lineage-based functional types (LFTs), situated between species-level trait data and PFT-level abstractions, thus providing a realistic representation of functional diversity and opening the door to the development of new vegetation models.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/nph.16773DOI Listing
October 2020

Measuring birth weight and umbilical cord diameter at birth to predict subsequent performance in swine.

Transl Anim Sci 2021 Jan 19;5(1):txaa214. Epub 2020 Nov 19.

Department of Animal Science, Iowa State University, Ames, IA.

In the swine industry, pre-weaning mortality, umbilical hernia incidence and pig market weight are a few contributing factors affecting profitability and welfare on farm. Therefore, the ability to reliably predict any of these outcomes is valuable to swine operations. Mortality during the pre-weaning phase, umbilical hernia incidence and poor-quality finisher pigs can represent a multi-million dollar loss and increase in welfare concerns to the producer. Consequently, the objective of this study was to evaluate whether birth weight (BW), umbilical cord diameter at birth (UCD), and the calculated umbilical diameter at birth to birth weight ratio (UCD:BW), are potential indicators of both placental efficiency and relative defect size in the abdominal musculature as well as reliable predictors of pre-weaning mortality, umbilical hernia incidence, and pig body weight at 150 d of age in a commercial facility. Mixed sex commercial piglets were followed through production. Four hundred sixty-five piglets were weighed within 1 h of birth, and the UCD was determined using digital calipers, these animals were followed through weaning. Three hundred eighty-five pigs of the 465 were followed through the post-wean phase in the nursery facility and checked for umbilical hernia incidence. Finally, of the 385 pigs, 177 pigs were assessed for umbilical hernia incidence and weighed a final time at the grower-finisher facility. All data were analyzed using PROC Logistic and PROC GLM procedures. The variables of UCD:BW and BW were significantly associated with the probability of increased pre-weaning mortality ( < 0.001). For example, piglets with a low UCD:BW, but an increased BW had the greatest survival rate. Umbilical diameter (UCD) was not significantly associated with pre-weaning mortality. Post-weaning mortality was not significantly affected by UCD:BW, BW, or UCD variables. Umbilical hernia incidence was not significantly affected by UCD:BW at the nursery phase or growing-finishing phase. Pig body weight at 150 d of age was significantly affected by UCD:BW, BW, and UCD variables < 0.001). For example, piglets that had a larger UCD weighed more at 150 d of age. In conclusion, measuring the calculated UCD:BW has the potential to be a novel tool for future research looking into the impacts of umbilical measurements as it relates to placental function, fetal development, piglet survivability and impacts on future performance of the animal.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/tas/txaa214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780433PMC
January 2021

Evolutionary dynamics of genome size in a radiation of woody plants.

Am J Bot 2020 11 20;107(11):1527-1541. Epub 2020 Oct 20.

Department of Ecology and Evolutionary Biology, Yale University, PO Box 208106, New Haven, CT, 06520, USA.

Premise: Plant genome size ranges widely, providing many opportunities to examine how genome size variation affects plant form and function. We analyzed trends in chromosome number, genome size, and leaf traits for the woody angiosperm clade Viburnum to examine the evolutionary associations, functional implications, and possible drivers of genome size.

Methods: Chromosome counts and genome size estimates were mapped onto a Viburnum phylogeny to infer the location and frequency of polyploidization events and trends in genome size evolution. Genome size was analyzed with leaf anatomical and physiological data to evaluate the influence of genome size on plant function.

Results: We discovered nine independent polyploidization events, two reductions in base chromosome number, and substantial variation in genome size with a slight trend toward genome size reduction in polyploids. We did not find strong relationships between genome size and the functional and morphological traits that have been highlighted at broader phylogenetic scales.

Conclusions: Polyploidization events were sometimes associated with rapid radiations, demonstrating that polyploid lineages can be highly successful. Relationships between genome size and plant physiological function observed at broad phylogenetic scales may be largely irrelevant to the evolutionary dynamics of genome size at smaller scales. The view that plants readily tolerate changes in ploidy and genome size, and often do so, appears to apply to Viburnum.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ajb2.1544DOI Listing
November 2020

COVID-19 and Newborn Care: April 2020.

Pediatrics 2020 11 26;146(5). Epub 2020 Aug 26.

Division of Neonatology, Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-002824DOI Listing
November 2020

Variability in the systems of care supporting critical neonatal intensive care unit transitions.

J Perinatol 2020 10 14;40(10):1546-1553. Epub 2020 Jul 14.

Vermont Oxford Network, Burlington, VT, USA.

Objective: Assess practices supporting care transitions for infants and families in the neonatal intensive care unit (NICU) using a model of four key drivers: communication, teamwork, family integration, and standardization.

Study Design: Single-day audit among NICUs in the Vermont Oxford Network Critical Transitions collaborative addressing policies and practices supporting the four key drivers during admission, discharge, shift-to-shift handoffs, within hospital transfers, and select changes in clinical status.

Results: Among 95 NICUs, the median hospital rate of audited policies in place addressing the four key drivers were 47% (inter-quartile range (IQR) 35-65%) for communication, 67% (IQR 33-83%) for teamwork, 50% (IQR 33-61%) for family integration, and 70% (IQR 56-85%) for standardization. Of the 2462 infants included, 1066 (43%) experienced ≥1 specified transition during the week prior to the audit.

Conclusions: We identified opportunities for improving NICU transitions in areas of communication, teamwork, family integration, and standardization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41372-020-0720-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359434PMC
October 2020

Optimizing High-risk Infant Follow-up in Nonresearch-based Paradigms: The New England Follow-up Network.

Pediatr Qual Saf 2020 May-Jun;5(3):e287. Epub 2020 May 5.

Division of Neonatology, Children's Hospital at Dartmouth, Lebanon, N.H.

Objectives: To establish the first regional quality improvement collaborative solely dedicated to follow-through care of high-risk infants after Neonatal intensive care unit (NICU) discharge and to characterize extremely low birth weight (ELBW) follow-up in New England.

Methods: Eleven of 14 follow-up programs in New England partnered with the Vermont Oxford Network (VON) ELBW project for an initial data collection project. We collected information about the health status and developmental outcomes of infants born ≤1,000 g or younger than 28 weeks 2014-2016 at the 18-24 months corrected for gestational age (CGA) follow-up visit. VON collected and compiled the data.

Results: Of 993 eligible infants, 516 (52.0%) had follow-up visits. The rehospitalization rate was 33.9%, mostly respiratory illness. Ninety-six children (19.3%) had weight less than 10th percentile and 44 (8.9%) had weight less than third percentile at 18-24 months. Only 170 (61.4%) children had recommended hearing screening after NICU discharge. Forty-six (9.1%) had cerebral palsy; 81 of the 441 infants that completed all 3 sections of the Bayley Scales of Infant Development, third edition (18.4%) had any composite score less than 70. Over half of the social and demographic data were missing.

Conclusion: Most quality initiatives in neonatology stop at NICU discharge. This first project by the New England Follow-up Network showed a low rate for clinical follow-up. It demonstrated many opportunities to improve postdischarge follow-through specific to NICU-based care. Future projects will aim to improve the quality of follow-through services through collaborative learning, data sharing, and comparative outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/pq9.0000000000000287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297406PMC
May 2020

Diversification in evolutionary arenas-Assessment and synthesis.

Ecol Evol 2020 Jun 19;10(12):6163-6182. Epub 2020 May 19.

Johannes Gutenberg-Universität Mainz Germany.

Understanding how and why rates of evolutionary diversification vary is a key issue in evolutionary biology, ecology, and biogeography. Evolutionary rates are the net result of interacting processes summarized under concepts such as adaptive radiation and evolutionary stasis. Here, we review the central concepts in the evolutionary diversification literature and synthesize these into a simple, general framework for studying rates of diversification and quantifying their underlying dynamics, which can be applied across clades and regions, and across spatial and temporal scales. Our framework describes the diversification rate () as a function of the abiotic environment (), the biotic environment (), and clade-specific phenotypes or traits (); thus, . We refer to the four components (-) and their interactions collectively as the "Evolutionary Arena." We outline analytical approaches to this framework and present a case study on conifers, for which we parameterize the general model. We also discuss three conceptual examples: the radiation in the Andes in the context of emerging ecological opportunity and fluctuating connectivity due to climatic oscillations; oceanic island radiations in the context of island formation and erosion; and biotically driven radiations of the Mediterranean orchid genus . The results of the conifer case study are consistent with the long-standing scenario that low competition and high rates of niche evolution promote diversification. The conceptual examples illustrate how using the synthetic Evolutionary Arena framework helps to identify and structure future directions for research on evolutionary radiations. In this way, the Evolutionary Arena framework promotes a more general understanding of variation in evolutionary rates by making quantitative results comparable between case studies, thereby allowing new syntheses of evolutionary and ecological processes to emerge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ece3.6313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319112PMC
June 2020

Our Responsibility to Follow Through for NICU Infants and Their Families.

Pediatrics 2020 12 16;146(6). Epub 2020 Jun 16.

Vermont Oxford Network, Burlington, Vermont.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-0360DOI Listing
December 2020

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network.

Pediatrics 2020 07 12;146(1). Epub 2020 Jun 12.

Department of Pediatrics, The Robert Larner, M.D. College of Medicine and.

Background: Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown.

Methods: The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program.

Results: Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine.

Conclusions: The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-3641DOI Listing
July 2020

Modeling Phylogenetic Biome Shifts on a Planet with a Past.

Syst Biol 2021 Jan;70(1):86-107

Department of Ecology & Evolutionary Biology, Yale University, PO Box 208106, New Haven, CT 06520, USA.

The spatial distribution of biomes has changed considerably over deep time, so the geographical opportunity for an evolutionary lineage to shift into a new biome may depend on how the availability and connectivity of biomes has varied temporally. To better understand how lineages shift between biomes in space and time, we developed a phylogenetic biome shift model in which each lineage shifts between biomes and disperses between regions at rates that depend on the lineage's biome affinity and location relative to the spatial distribution of biomes at any given time. To study the behavior of the biome shift model in an empirical setting, we developed a literature-based representation of paleobiome structure for three mesic forest biomes, six regions, and eight time strata, ranging from the Late Cretaceous (100 Ma) through the present. We then fitted the model to a time-calibrated phylogeny of 119 Viburnum species to compare how the results responded to various realistic or unrealistic assumptions about paleobiome structure. Ancestral biome estimates that account for paleobiome dynamics reconstructed a warm temperate (or tropical) origin of Viburnum, which is consistent with previous fossil-based estimates of ancestral biomes. Imposing unrealistic paleobiome distributions led to ancestral biome estimates that eliminated support for tropical origins, and instead inflated support for cold temperate ancestry throughout the warmer Paleocene and Eocene. The biome shift model we describe is applicable to the study of evolutionary systems beyond Viburnum, and the core mechanisms of our model are extensible to the design of richer phylogenetic models of historical biogeography and/or lineage diversification. We conclude that biome shift models that account for dynamic geographical opportunities are important for inferring ancestral biomes that are compatible with our understanding of Earth history.[Ancestral states; biome shifts; historical biogeography; niche conservatism; phylogenetics].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/sysbio/syaa045DOI Listing
January 2021

Joint Phylogenetic Estimation of Geographic Movements and Biome Shifts during the Global Diversification of Viburnum.

Syst Biol 2021 Jan;70(1):67-85

Department of Ecology & Evolutionary Biology, Yale University, PO Box 208106, New Haven, CT 06520, USA.

Phylogeny, molecular sequences, fossils, biogeography, and biome occupancy are all lines of evidence that reflect the singular evolutionary history of a clade, but they are most often studied separately, by first inferring a fossil-dated molecular phylogeny, then mapping on ancestral ranges and biomes inferred from extant species. Here we jointly model the evolution of biogeographic ranges, biome affinities, and molecular sequences, while incorporating fossils to estimate a dated phylogeny for all of the 163 extant species of the woody plant clade Viburnum (Adoxaceae) that we currently recognize in our ongoing worldwide monographic treatment of the group. Our analyses indicate that while the major Viburnum lineages evolved in the Eocene, the majority of extant species originated since the Miocene. Viburnum radiated first in Asia, in warm, broad-leaved evergreen (lucidophyllous) forests. Within Asia, we infer several early shifts into more tropical forests, and multiple shifts into forests that experience prolonged freezing. From Asia, we infer two early movements into the New World. These two lineages probably first occupied warm temperate forests and adapted later to spreading cold climates. One of these lineages (Porphyrotinus) occupied cloud forests and moved south through the mountains of the Neotropics. Several other movements into North America took place more recently, facilitated by prior adaptations to freezing in the Old World. We also infer four disjunctions between Asia and Europe: the Tinus lineage is the oldest and probably occupied warm forests when it spread, whereas the other three were more recent and in cold-adapted lineages. These results variously contradict published accounts, especially the view that Viburnum radiated initially in cold forests and, accordingly, maintained vessel elements with scalariform perforations. We explored how the location and biome assignments of fossils affected our inference of ancestral areas and biome states. Our results are sensitive to, but not entirely dependent upon, the inclusion of fossil biome data. It will be critical to take advantage of all available lines of evidence to decipher events in the distant past. The joint estimation approach developed here provides cautious hope even when fossil evidence is limited. [Biogeography; biome; combined evidence; fossil pollen; phylogeny; Viburnum.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/sysbio/syaa027DOI Listing
January 2021

Trends in incidence and outcomes of necrotizing enterocolitis over the last 12 years: A multicenter cohort analysis.

J Pediatr Surg 2020 Jun 29;55(6):998-1001. Epub 2020 Feb 29.

Department of Surgery and Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA. Electronic address:

Objective: We sought to describe changes in the incidence and mortality of necrotizing enterocolitis (NEC) and associated surgical management strategies for very low birth weight (VLBW) infants.

Methods: Data were prospectively collected on VLBW infants (≤1500 g or < 29 weeks) born 2006 to 2017 and admitted to 820 U.S. centers. NEC was defined by the presence of at least one clinical and one radiographic finding. Trends analyses were performed to assess changes in incidence and mortality over time.

Results: Of 473,895 VLBW infants, 36,130 (7.6%) were diagnosed with NEC, of which 21,051 (58.3%) had medical NEC and 15,079 (41.7%) had surgical NEC. Medical NEC decreased from 5.3% to 3.0% (p < 0.0001). Surgical NEC decreased from 3.4% to 3.1% (p = 0.06). Medical NEC mortality decreased from 20.7% to 16.8% (p = 0.003), while surgical NEC mortality decreased from 36.6% to 31.6% (p < 0.0001). In the surgical cohort, the use of primary peritoneal drainage (PPD) versus initial laparotomy rose from 23.2% to 46.8%.

Conclusion: The incidence and mortality of both medical and surgical NEC have decreased over time. Changes in surgical management during this time period included the increased utilization of primary peritoneal drainage.

Type Of Study: Prognosis study.

Level Of Evidence: Level II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.02.046DOI Listing
June 2020

Regional and Racial-Ethnic Differences in Perinatal Interventions Among Periviable Births.

Obstet Gynecol 2020 04;135(4):885-895

Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; the Vermont Oxford Network, the Department of Mathematics and Statistics, University of Vermont, and the Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont; and the Department of Obstetrics & Gynecology, the University of Texas Medical Branch at Galveston, Galveston, Texas.

Objective: To examine whether there are: 1) regional differences in three perinatal interventions that reflect active treatment among periviable gestations and 2) racial-ethnic differences in the receipt of these perinatal interventions after accounting for hospital region.

Methods: We conducted a retrospective study on neonates born at 776 U.S. centers that participated in the Vermont Oxford Network (2006-2017) with a gestational age of 22-25 weeks. The primary outcome was postnatal life support. Secondary outcomes included maternal administration of antenatal corticosteroids and cesarean delivery. We examined rates and 99% CI of the three outcomes by region. We also calculated the adjusted relative risks (aRRs) and 99% CIs for the three outcomes by race and ethnicity within each region using modified Poisson regression models with robust variance estimation.

Results: Major regional variation exists in the use of the three interventions at 22 and 23 weeks of gestation but not at 24 and 25 weeks. For example, at 22 weeks of gestation, rates of life support in the South (38.3%; 99% CI 36.3-40.2) and the Midwest (32.7%; 99% CI 30.4-35.0) were higher than in the Northeast (20.2%; 99% CI 17.6-22.8) and the West (22.2%; 99% CI 20.0-24.4). Particularly in the Northeast, black and Hispanic neonates born at 22 or 23 weeks of gestation had a higher provision of postnatal life support than white neonates (at 22 weeks: black: aRR 1.84 [99% CI 1.33-2.56], Hispanic: aRR 1.80 [1.23-2.64]; at 23 weeks: black: aRR 1.14 [99% CI 1.08-1.20], Hispanic: aRR 1.12 [1.05-1.19]). In the West, black and Hispanic neonates born at 23 weeks of gestation also had a higher provision of life support (black: aRR 1.11 [99% CI 1.03-1.19]; Hispanic: aRR 1.10 [1.04-1.16]).

Conclusion: Major regional variation exists in perinatal interventions when managing 22- and 23-week neonates. In the Northeast and the West regions, minority neonates born at 22 and 23 weeks of gestation had higher provision of postnatal life support.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000003747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103505PMC
April 2020

Assessment of an Updated Neonatal Research Network Extremely Preterm Birth Outcome Model in the Vermont Oxford Network.

JAMA Pediatr 2020 05 4;174(5):e196294. Epub 2020 May 4.

Office of Research, George Mason University College of Health and Human Services, Fairfax, Virginia.

Importance: The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals.

Objective: To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States.

Design, Setting, And Participants: This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks' 0 days' to 25 weeks' 6 days' gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019.

Exposures: Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids.

Main Outcomes And Measures: The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months' corrected age and measures of hospital resource use (days of hospitalization and ventilator use).

Results: Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age-only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%).

Conclusions And Relevance: An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamapediatrics.2019.6294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052789PMC
May 2020

Tracheostomy in Very Low Birth Weight Infants: A Prospective Multicenter Study.

Pediatrics 2020 03 25;145(3). Epub 2020 Feb 25.

Department of Surgery and Center for Advanced Intestinal Rehabilitation, and

Objectives: In this study, we benchmark outcomes and identify factors associated with tracheostomy placement in infants of very low birth weight (VLBW).

Methods: Data were prospectively collected on infants of VLBW (401-1500 g or gestational age of 22-29 weeks) born between 2006 and 2016 and admitted to 796 North American centers. Length of stay (LOS), mortality, associated surgical procedures, and comorbidities were assessed, and infants who received tracheostomy were compared with those who did not. Multivariable logistic regressions were performed to identify risk factors for tracheostomy placement and for mortality in those receiving tracheostomy.

Results: Of 458 624 infants of VLBW studied, 3442 (0.75%) received tracheostomy. Infants with tracheostomy had a median (interquartile range) LOS of 226 (168-304) days and a mortality rate of 18.8%, compared with 58 (39-86) days and 8.3% for infants without tracheostomy. Independent risk factors associated with tracheostomy placement included male sex, birth weight <1001 g, African American non-Hispanic maternal race, chronic lung disease (CLD), intraventricular hemorrhage, patent ductus arteriosus ligation, and congenital neurologic, cardiac, and chromosomal anomalies. Among infants who received tracheostomy, male sex, birth weight <751 g, CLD, and congenital anomalies were independent predictors of mortality.

Conclusions: Infants of VLBW receiving tracheostomy had twice the risk of mortality and nearly 4 times the initial LOS of those without tracheostomy. CLD and congenital anomalies were the strongest predictors of tracheostomy placement and mortality. These benchmark data on tracheostomy in infants of VLBW should guide discussions with patient families and inform future studies and interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-2371DOI Listing
March 2020

Crassulacean acid metabolism.

Curr Biol 2020 01;30(2):R57-R62

Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA.

Gilman and Edwards introduce crassulacean acid metabolism and highlight how recent advances in molecular biology are deepening our knowledge of CAM evolution.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cub.2019.11.073DOI Listing
January 2020

Crassulacean acid metabolism.

Curr Biol 2020 01;30(2):R57-R62

Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA.

Gilman and Edwards introduce crassulacean acid metabolism and highlight how recent advances in molecular biology are deepening our knowledge of CAM evolution.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cub.2019.11.073DOI Listing
January 2020

A Collaborative Multicenter QI Initiative to Improve Antibiotic Stewardship in Newborns.

Pediatrics 2019 12 1;144(6). Epub 2019 Nov 1.

Vermont Oxford Network, Burlington, Vermont.

Objectives: To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns.

Methods: From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit.

Results: The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%-68.8%; accountability: 54.5%-95%; drug expertise: 61.5%-85.1%; actions: 21.7%-72.3%; tracking: 14.7%-78%; reporting: 6.3%-17.7%; education: 32.9%-87.2%; < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% ( for trend < .0013), a 34% relative risk reduction.

Conclusions: NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-0589DOI Listing
December 2019
-->