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ABSTRACT: Nursing students are frequently assigned to provide case or topical presentations in class. They are often nervous about presenting, which can distract them from learning from peers. Faculty introduced the role of the assigned discussant to enhance engagement and enable peer feedback in real time. After students presented a brief elevator-pitch style speech, peer discussants were instructed to respond following specific prompts to reflect on key takeaways and remaining questions. Faculty coached students to demonstrate focused, active listening skills and to provide quality feedback using this teaching-learning innovation. Students were enthusiastic about providing and receiving immediate, constructive collegial peer support.

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BACKGROUND: Advanced neonatal resuscitation events are high-risk, low-volume critical situations. Healthcare systems have placed emphasis on improving resuscitation skills for advanced providers based on evidence showing that it can directly impact patient outcomes. Neonatal resuscitation program (NRP) renewal is only required every 2 years. This gap and low usage of skills can result in lack of competency and expertise leading to an increased risk of poor patient outcomes. PURPOSE: This project aimed to provide simulation education based on NRP curriculum for a large group of advanced providers at multiple level II, III, and IV neonatal intensive care units (NICUs) and to improve confidence and knowledge in advanced resuscitation. METHODS: A high-fidelity mannequin was used to simulate a reproducible, critical scenario that spanned the entire NRP algorithm. NRP knowledge and the effectiveness of simulation on confidence and knowledge in neonatal resuscitation were measured. RESULTS: The average knowledge score from the pretest to the posttest improved by 7%. Based on the simulation evaluation tool-modified (SET-M), debriefing was the most effective in improving confidence and knowledge. The neonatal nurse practitioners (NNPs) with the most years of clinical experience had the largest improvement in knowledge. IMPLICATIONS FOR PRACTICE AND RESEARCH: With the most experienced NNPs providing majority of coverage in the Level II NICUs, a correlation may be drawn that the effect of simulations on NRP knowledge has a greater impact on these groups due to the low exposure of advanced resuscitation events at these sites. Debriefing stood out as the most critical component of simulation.

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BACKGROUND: Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500 g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants. PURPOSE: For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration. METHODS: The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500 g. RESULTS: The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data. IMPLICATIONS FOR PRACTICE AND RESEARCH: Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.

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The need for neonatal nurse practitioner (NNP) preceptors has never been greater. Precepting is a professional responsibility with both rewards and challenges. The recent pandemic has brought about new challenges, not the least of which is burnout from clinical, learner, and environmental demands. A new educational model from the American Association of Colleges of Nursing and the National Task Force outlines educational and preceptor requirements aimed at improving the advanced practice educational experience for students and preceptors. Available research provides evidence of what preceptors value and how to develop best practices with academic institutions to advocate for their students. This article will discuss new nursing educational models and the role of the NNP preceptor and analyze current best practices in preceptor recruitment and retention while discussing national trends impacting personal and professional NNP practices.

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Purpose: To evaluate the safety and efficacy of a preservative-free latanoprost 0.005% formulation (T2345) in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT) compared to benzalkonium chloride-preserved latanoprost 0.005% (BPL) formulation in the United States (US). Patients and Methods: A prospective, randomized, multicenter, observer-masked, parallel-group study enrolled 335 patients diagnosed with POAG or OHT from 31 US sites who had adequately controlled intraocular pressure (IOP; ≤18 mm Hg) with latanoprost monotherapy. After a ≥72-hour washout period, patients were randomized to T2345 (n=165) or BPL (n=170) groups. Study drugs were dosed once-daily from Day 0 to Day 84 in one or both eyes. The study eye was the eye with lower IOP at baseline. The primary efficacy measure was the between-group comparison of the mean IOP values in the study eye at each time point (8 AM, 10 AM, and 4 PM on Days 15, 42, and 84). Safety measurements included ocular and systemic treatment-emergent adverse events (TEAEs). Results: Both T2345 and BPL adequately controlled IOP with 95% CIs within 1.5 mm Hg in the study eye at all assessed time points. The percentages of patients with diurnal IOP <18 mm Hg at Day 84 were 73.1% vs 78.7% for the T2345 and BPL groups, respectively. Adverse events were generally mild-to-moderate and primarily ocular. Fewer patients in the T2345 group experienced ocular TEAEs (13.9% vs 22.5%, respectively) and TEAEs with a suspected relationship to the study medication compared with the BPL group (5.5% vs 11.8%, respectively). The most common ocular TEAEs were instillation site pain and conjunctival hyperemia. Conclusion: In patients with POAG or OHT, both T2345 and BPL maintained IOP at or below clinically meaningful values for the duration of the study. T2345 showed a favorable safety profile, with numerically lower incidences of ocular TEAEs than BPL.

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Mutations in the gene encoding polycystin-1 (PC1) are the most common cause of autosomal dominant polycystic kidney disease (ADPKD). Cysts in ADPKD exhibit a Warburg-like metabolism characterized by dysfunctional mitochondria and aerobic glycolysis. PC1 is an integral membrane protein with a large extracellular domain, a short C-terminal cytoplasmic tail and shares structural and functional similarities with G protein-coupled receptors. Its exact function remains unclear. The C-terminal cytoplasmic tail of PC1 undergoes proteolytic cleavage, generating soluble fragments that are overexpressed in ADPKD kidneys. The regulation, localization, and function of these fragments is poorly understood. Here, we show that a ∼30 kDa cleavage fragment (PC1-p30), comprising the entire C-terminal tail, undergoes rapid proteasomal degradation by a mechanism involving the von Hippel-Lindau tumor suppressor protein. PC1-p30 is stabilized by reactive oxygen species, and the subcellular localization is regulated by reactive oxygen species in a dose-dependent manner. We found that a second, ∼15 kDa fragment (PC1-p15), is generated by caspase cleavage at a conserved site (Asp-4195) on the PC1 C-terminal tail. PC1-p15 is not subject to degradation and constitutively localizes to the mitochondrial matrix. Both cleavage fragments induce mitochondrial fragmentation, and PC1-p15 expression causes impaired fatty acid oxidation and increased lactate production, indicative of a Warburg-like phenotype. Endogenous PC1 tail fragments accumulate in renal cyst-lining cells in a mouse model of PKD. Collectively, these results identify novel mechanisms regarding the regulation and function of PC1 and suggest that C-terminal PC1 fragments may be involved in the mitochondrial and metabolic abnormalities observed in ADPKD.

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BACKGROUND: Neonatal herpes simplex virus (HSV) infections can be challenging to diagnose and often occur without maternal history of infection. Routine initial pharmacologic management when a neonate presents with signs of sepsis in the first weeks of life typically targets antibiotic therapies. This case illustrates the importance of the addition of antiviral coverage, especially when a neonate demonstrates temperature instability and neurologic changes. CLINICAL FINDINGS: This case report describes the unique presentation of a 9-day old neonate with clinical findings significant for sepsis. This neonate was diagnosed with methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia with concomitant disseminated HSV-2 infection after presenting with temperature instability, lethargy, and signs of multisystem organ impairment. PRIMARY DIAGNOSIS: This neonate was diagnosed with disseminated HSV infection, which occurs in 25% of neonatal HSV disease. INTERVENTIONS: Treatment was initiated with high-dose intravenous acyclovir at 20 mg/kg/dose every 8 hours along with broad-spectrum antibiotics. Management should include anticipating and monitoring for progressive multisystem organ failure in bacterial or viral infection. OUTCOMES: This patient did not survive despite maximal intervention from the neonatal intensive care unit team. Disseminated HSV neonatal infections are associated with high mortality rates when they are present alone, and mortality is higher with concurrent bacteremia. PRACTICE RECOMMENDATIONS: Providers should have a high index of suspicion for HSV infection in neonates presenting in the first 1 to 3 weeks of life with signs of sepsis. Prophylactic treatment with high-dose acyclovir as an adjunct to broad-spectrum antibiotics while awaiting laboratory confirmation can be lifesaving.

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BACKGROUND: The COVID-19 pandemic necessitated sweeping changes in a neonatal nurse practitioner (NNP) program's approach to distance-accessible learning. Prioritizing student learning and safety, we developed a new alternative model for individualized simulation. METHOD: The scenario created for a student to deliver an unexpected diagnosis of trisomy 21, or Down syndrome, to a postpartum mother was redesigned to take place using web-conference technology. RESULTS: We successfully transitioned the planned in-person individualized simulation for NNP students delivering an unexpected diagnosis to a web-conference environment and added nurse-midwifery (NM) students. CONCLUSION: This simulation presented an authentic clinical situation encountered in practice, supporting the specialty-specific competencies for the NNP, NM, and core competencies for interprofessional collaborative practice. The web-conference platform is an effective strategy for simulation. Advanced practice nurses completing individualized simulation through technology are uniquely poised to leverage these skills as telemedicine increasingly influences their future clinical practice. [J Nurs Educ. 2021;60(6):346-351.].

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BACKGROUND: The The Neonatal Nurse Practitioner program at The Ohio State University transitioned from a traditional face-to-face program to a distance-enhanced hybrid model providing course content online with campus visits for procedural skills and simulation in 2017. Although the 2020 COVID-19 pandemic necessitated cancellation of all in-person events across the university, the neonatal nurse practitioner students' learning needs remained the same. METHOD: The onsite experience was redesigned for virtual delivery. Procedural content was accomplished through student-led small-group collaborative critical thinking activities surrounding procedural complications, and other faculty-led scenario discussions. RESULTS: Students collaborated for a Complications Rounds activity (1-day) that promoted learning about procedural skills from a global perspective including safe techniques, monitoring, risks, and troubleshooting complications. CONCLUSION: Procedural content can be achieved when in-person learning is not possible. The Complications Rounds approach can mitigate delays or gaps in practical experiences. Examining complications in-depth increases preparedness, promoting greater awareness of harm prevention when these present in future practice. [J Nurs Educ. 2020;59(12):692-696.].

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BACKGROUND: Hypoxic-ischemic encephalopathy (HIE) remains devastating for neonates despite widespread treatment with therapeutic hypothermia (TH). The heart rate characteristic (HRC) index score, a measure of heart rate variability, could prove useful in the management of neonates with HIE as new therapies emerge or when withdrawal-of-support decisions are being considered. PURPOSE: The main purpose was to describe correlation between HRC index scores and brain magnetic resonance imaging (MRI) severity of injury for neonates with HIE. METHODS/ANALYSIS: Low/high HRC index scores retrieved at initiation of TH (baseline), 24, 48, 72, and 96 hours, brain MRI severity of injury, and National Institute of Child Health and Human Development Death/Disability and Death scores were collected and analyzed retrospectively. Independent t tests and linear regression were used to examine relationships for each outcome measure. RESULTS: Twenty-seven neonates were stratified into 2 groups: noninjury (n = 11) and injury (n = 16). Statistically significant relationships were observed. Strikingly, mean low HRC index score for the noninjury group ranged between 0.37 and 0.65 and was between 0.61 and 0.86 for the injury group. Mean high HRC index score for the noninjury group ranged between 0.66 and 1.02 and was between 1.04 and 1.41 for the injury group. IMPLICATIONS FOR PRACTICE: HRC index score may be a useful guide in the future management of neonates with HIE. IMPLICATIONS FOR RESEARCH: This study established correlations between HRC index and MRI injury scores in neonates treated with TH. Further research is warranted to establish important relationships between brain injury and HRC index scores before this tool can be used clinically for this purpose.

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BACKGROUND: Neonates are at greater risk for central line-associated bloodstream infection (CLABSI) because of prolonged vascular access for nutrition and medications. Skin antisepsis using chlorhexidine gluconate (CHG), particularly the formulation with alcohol (CHG/alcohol), during central line insertion and maintenance activities is a key clinical care process associated with CLABSI reduction. One area of ongoing confusion for many clinicians is whether to adhere to the manufacturer's recommendations that CHG remain on the skin following the procedure to promote persistent microbicidal effects or to foster product removal in hopes of preventing skin-related complications. PURPOSE: Determine the effect of a targeted education program on the knowledge and attitudes of nurses who place peripherally inserted central catheters in the NICU regarding the use and removal of CHG antiseptic. METHODS: A quasi-experimental presurvey/postsurvey quality improvement project (QI project) recruited participants from the electronic mailing list of a national neonatal nursing organization. RESULTS: There was a statistically significant deficiency in knowledge or misinformation related to the use of CHG/alcohol on the presurvey assessment. Eight questions reflecting knowledge consistent with most recent evidence were answered correctly only 11.4-25.7 percent of the time, all of which were considered statistically significant. Following completion of the education program, a nearly 100 percent correct response rate on all but three postsurvey questions resulted. CONCLUSIONS: This quality improvement project demonstrated success in the ability to change knowledge surrounding the removal of CHG/alcohol from the skin of babies in the NICU following completion of a targeted education program and the effectiveness of targeted web-based educational programs.

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BACKGROUND: Neonatal intensive care units (NICUs) commonly utilize peripherally inserted central catheters (PICCs) to provide nutrition and long-term medications to premature and full-term infants. However, little is known about PICC practices in these settings. PURPOSE: To assess PICC practices, policies, and providers in NICUs. METHODS: The Neonatal PICC1 Survey was conducted through the use of the electronic mailing list of a national neonatal professional organization's electronic membership community. Questions addressed PICC-related policies, monitoring, practices, and providers. Descriptive statistics were used to assess results. RESULTS: Of the 156 respondents accessing the survey, 115 (73.7%) indicated that they placed PICCs as part of their daily occupation. Of these, 110 responded to at least one question (70.5%) and were included in the study. Reported use of evidence-based practices by NICU providers varied. For example, routine use of maximum sterile barriers was reported by 90.4% of respondents; however, the use of chlorhexidine gluconate for skin disinfection was reported only by 49.4% of respondents. A majority of respondents indicated that trained PICC nurses were largely responsible for routine PICC dressing changes (61.0%). Normal saline was reported as the most frequently used flushing solution (46.3%). The most common PICC-related complications in neonates were catheter migration and occlusion. IMPLICATIONS FOR PRACTICE: Variable practices, including the use of chlorhexidine-based solutions for skin disinfection and inconsistent flushing, exist. There is a need for development of consistent monitoring to improve patient outcomes. IMPLICATIONS FOR RESEARCH: Future research should include exploration of specific PICC practices, associated conditions, and outcomes.

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AIMS: To compare outcomes of resident-performed Ahmed valve surgery vs trabeculectomy in a Veteran Affairs medical facility. MATERIALS AND METHODS: A retrospective cohort of 103 eyes in 91 patients receiving Ahmed valve (valve) or trabeculectomy (trab) performed at a Veterans Administration Medical Center by residents in their third year of training. The primary outcomes included intraocular pressure (IOP), treatment failure, and complications over 1 year. RESULTS: Of 103 eyes, 44 received valve and 59 received trab. Primary open-angle glaucoma was primary diagnosis more often in trab, while neovascular glaucoma predominated in the valve group (p < 0.001). Preoperative mean IOP was 35.1 ± 11.8 and 24.5 ± 7.1 mm Hg for valve and trabeculectomy respectively (p < 0.001), but at 1 year the IOP difference between groups was not statistically significant (p = 0.064). Overall, 11 (25.0%) and 11 (18.6%) eyes met any criteria for failure for valve and trab respectively. At 1 year, 22.5% of valves had IOP > 21 mm Hg vs only 4.3% of trab (p = 0.02). Complications were infrequent. There were no intraoperative complications for valve, whereas five for trab. Most common immediate complication for valve was hyphema. Both groups had low rates of choroidal effusions and reoperation. CONCLUSION: Ahmed valve implantation and trabeculectomy produce significant reductions in IOP when performed by residents-in-training. Valves tend to be used more frequently in patients with secondary glaucoma. Although complication profiles differ between procedures, both are safe and well tolerated when performed by resident physicians. CLINICAL SIGNIFICANCE: This study provides support for evidence-based patient counseling that supervised, resident-performed Ahmed valve implantation and trabeculectomy are indeed safe and effective. How to cite this article: Sharpe RA, Kammerdiener LL, Wannamaker KW, Fan J, Sharpe ED. Comparison of Outcomes of Resident-performed Ahmed Valve Implantation vs Trabeculectomy. J Curr Glaucoma Pract 2016;10(2):60-67.

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The goal of this secondary analysis of results from a national survey of peripherally inserted central catheters (PICCs) practices in neonates was to determine whether demographics and types of training were associated with differing radiographic confirmation practices of these catheters. Correlational analyses were performed on the 2010 national database of neonatal PICC practices. The sample consisted of 187 respondents, representing 25% of the level III neonatal intensive care units (NICUs) of more than 20 beds in the United States. The key factors examined were geographic location, size of NICU, academic affiliation, and type of training related to radiographic confirmation of the catheter tip position, routine monitoring and reconfirmation of the catheter tip position following adjustments, and associated patient positioning practices for consistent evaluation of the catheter tip position. Formal training and annual retraining were statistically significantly associated with consistent patient positioning practices for more accurate monitoring of the catheter tip position and acceptable tip location. Size of NICU and academic affiliation were not associated with differences in practices. Adherence to specific national guidelines and recommendations for care of infants with PICCs is significantly impacted by formal training and annual retraining. This underscores the importance of education and annual retraining in preventing PICC-related complications beyond the crucial prevention of central line-associated bloodstream infections.

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PURPOSE: The purpose of this study was to assess and describe the practices involved in the insertion and maintenance of peripherally inserted central catheters (PICCs) in neonates in level III neonatal intensive care units (NICUs) in the United States and to compare the findings with current recommendations and evidence. SUBJECTS: The study included responses from 187 nurses, nurse practitioners, and neonatologists who place PICCs in NICUs representing 43 states. METHODS: A 90-question, multiple-choice survey of a variety of PICC practices was sent to NICU directors and nursing staff responsible for PICC insertion. The explorative survey was sent by electronic and standard mail services. A descriptive analysis of the responses was performed. MAIN OUTCOME MEASURES: Main outcome measures included the response rate to the survey and the summarized responses of multiple categories of PICC practices. PRINCIPAL RESULTS: Of the 460 level III NICUs contacted, 187 returned surveys meeting criteria for analysis, yielding a 42% response rate. Responses showed wide variation of PICC practices in multiple aspects of PICC insertion and maintenance. The greatest level of conformity was seen with the following practices: use of 2 nurses to perform a dressing change, trimming the PICC, using a kit or cart containing insertion supplies, use of maximal sterile barrier precautions during insertion, catheter tip residing in the superior vena cava for upper body insertions, and not heparin locking, infusing blood products, performing catheter repair, or inserting using Modified Seldinger Technique. Some identified practices, such as infusion tubing change and catheter entry techniques, were contrary to current evidence and demonstrated a lack of correct information, and some represented safety concerns for the neonates having PICCs. CONCLUSION: This extensive national survey of NICU PICC practices showed wide variation in multiple aspects of PICC insertion and maintenance. A gap between the evidence and current practice was evident in many facets of training, insertion techniques, and maintenance processes. The data suggest a need for an increase in awareness of clinicians of current practice guidelines and standards and the need for further research to develop an evidence basis for many aspects of PICC care where lacking.

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