The physiologic definition of BPD reduced the overall rate of BPD and reduced the variation among centers. Significant center differences in the impact of the physiologic definition were seen, and differences remained even with the use of this standardized definition. The magnitude of the change in BPD rate is comparable to the magnitude of treatment effects seen in some clinical trials in BPD. The physiologic definition of BPD facilitates the measurement of BPD as an outcome in clinical trials and the comparison between and within centers over time.

OBJECTIVE-Invasive candidiasis is a leading cause of infection-related morbidity and mortality in extremely low-birth-weight (<1000 g) infants. We quantify risk factors predicting infection in high-risk premature infants and compare clinical judgment with a prediction model of invasive candidiasis. METHODS-The study involved a prospective observational cohort of infants <1000 g birth weight at 19 centers of the NICHD Neonatal Research Network. At each sepsis evaluation, clinical information was recorded, cultures obtained, and clinicians prospectively recorded their estimate of the probability of invasive candidiasis. Two models were generated with invasive candidiasis as their outcome: 1) potentially modifiable risk factors and 2) a clinical model at time of blood culture to predict candidiasis.RESULTS-Invasive candidiasis occurred in 137/1515 (9.0%) infants and was documented by positive culture from ≥ 1 of these sources: blood (n=96), cerebrospinal fluid (n=9), urine obtained by catheterization (n=52), or other sterile body fluid (n=10). Mortality was not different from infants who had positive blood culture compared to those with isolated positive urine culture. Incidence varied from 2-28% at the 13 centers enrolling ≥ 50 infants. Potentially modifiable risk factors (model 1) included central catheter, broad-spectrum antibiotics (e.g., third-generation cephalosporins), intravenous lipid emulsion, endotracheal tube, and antenatal antibiotics. The clinical prediction model (model 2) had an area under the receiver operating characteristic curve of 0.79, and was superior to clinician judgment (0.70) in predicting subsequent invasive candidiasis. Performance of clinical judgment did not vary significantly with level of training. CONCLUSION-Priorantibiotics, presence of a central catheter, endotracheal tube, and center were strongly associated with invasive candidiasis. Modeling was more accurate in predicting invasive candidiasis than clinical judgment. KeywordsCandidiasis; premature infant; risk factors In the extremely low-birth-weight (ELBW; <1000g) infant, invasive candidiasis is common, often fatal, and frequently leads to poor neurodevelopmental outcomes. 1,2 Invasive candidiasis (Candida infections of the blood and other sterile body fluids) is the second most common cause of infectious disease-related death in the extremely premature infant. Despite antifungal treatment, 20% of infants who develop invasive candidiasis die, and neurodevelopmental impairment occurs in nearly 60% of survivors. 1,2 Rates of invasive candidiasis vary 10-fold among similar academic tertiary care neonatal intensive care units (NICUs). 3 This variation among nurseries is found throughout the world 4-9 and has not been explained, but exposure to environmental risk factors (e.g., incubator humidity), third-generation cephalosporins, and foreign bodies such as catheters have all been associated with development of disease. 3,10,11 The high morbidity related to invasive candidiasis leads to the consideration of empirical anti...

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Objectives To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates. Study design This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network’s Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks’ gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation. Results Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/bronchopulmonary dysplasia (OR 3.27). Conclusions Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities. Trial registration ClinicalTrials.gov: NCT00233324.

Federal, state, and local government disaster preparedness plans should specify criteria for timely evacuation orders, needed resources, and their allocation (including a decentralized distribution system for cash or vouchers for gas and incidentals during evacuation) and culturally sensitive logistic planning for the evacuation of minority, low-income, and underserved communities. Perceptions of racism and inequities warrant further investigation.

The factors policy makers might consider changing include increasing the number of residential care beds and home health agencies, removing certificate of need for home health care, using Medicare home health reimbursement methods for Medicaid, and raising the Medicaid eligibility criteria. In some states with low nursing home occupancy rates, reducing the supply of nursing home beds may also be considered. All of these approaches would be controversial and should be based on additional cost-effectiveness analysis.

Objective To evaluate the temperature distribution among moderately preterm (MPT, 29–33 weeks) and extremely preterm (EPT, <29 weeks) infants upon neonatal intensive care unit (NICU) admission in 2012–2013, the change in admission temperature distribution for EPT infants between 2002–2003 and 2012–2013, and associations between admission temperature and mortality and morbidity for both MPT and EPT infants. Study design Prospectively collected data from 18 centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network were used to examine NICU admission temperature of inborn MPT and EPT infants. Associations between admission temperature and mortality and morbidity were determined by multivariable logistic regression. EPT infants from 2002–2003 and 2012–2013 were compared. Results MPT and EPT cohorts consisted of 5818 and 3213 infants, respectively. The distribution of admission temperatures differed between the MPT vs EPT (P < .01), including the percentage <36.5°C (38.6% vs 40.9%), 36.5°C–37.5°C (57.3% vs 52.9%), and >37.5°C (4.2% vs 6.2%). For EPT infants in 2012–2013 compared with 2002–2003, the percentage of temperatures between 36.5°C and 37.5°C more than doubled and the percentage of temperatures >37.5°C more than tripled. Admission temperature was inversely associated with in-hospital mortality. Conclusions Low and high admission temperatures are more frequent among EPT than MPT infants. Compared with a decade earlier, fewer EPT infants experience low admission temperatures but more have elevated temperatures. In spite of a change in distribution of NICU admission temperature, an inverse association between temperature and mortality risk persists.

This paper reviews recent research on sex differences in the nature of alcohol and drug problems, use of treatment services, and the role of treatment and extratreatment factors in influencing these problems. Although patterns of use are different for men and women, responses to traditional treatment programs have not been different. Research suggests that programs providing ancillary services designed to meet the particular needs of women, such as child care, and those involving other family members and significant others hold the greatest promise for women with drug and alcohol problems.