bluuebunny/crossref_metadata_2025 huggingface dataset:
Lost in translation: impact of language barriers on children's healthcare
Authors: Goenka Pratichi K.
Published: August 2016

Purpose of review

As the cultural and linguistic diversity of the United States grows, a greater number of patients with limited English proficiency will enter the healthcare system. Best practices for the care of these individuals include identification of their language assistance needs and prompt provision of interpreter services. This review will summarize the legal basis for providing language access in the healthcare setting, discuss the impact of interpretation services on clinical care, and explore the effects of language barriers on health outcomes.

Recent findings

There has been greater awareness of language as an important and independent determinant in the racial and ethnic disparities that exist in healthcare. Studies have shown that there is suboptimal identification of patients who require linguistic assistance and, as such, there are missed opportunities to bridge language gaps with many of our patients. The lack of interpretation, or use of informal, untrained interpreters, has significant effects on patient safety, quality of care, and patient satisfaction.

Though federal and regulatory guidelines mandate meaningful access to language services, such processes are still a work in progress in many healthcare settings. Further research and quality improvement initiatives are needed to provide clinicians the knowledge and skills needed to effectively communicate with their limited English proficient patients.
Pokémon Go and augmented virtual reality games: a cautionary commentary for parents and pediatricians
Authors: Serino Maeve , Cordrey Kyla , McLaughlin Laura , Milanaik Ruth L.
Published: August 2016

Purpose of review

The recent release of Pokémon Go has ushered in a new set of challenges for parents and pediatricians, highlighting the importance of parents setting guidelines for video game use with their children. Within 1 week of its launch, the game attracted over 65 million users, many of whom are young children. Despite the potential benefits of the game described in our article, this location-based game format poses specific threats to the safety and physical wellbeing of children.

Recent findings

Reports have discussed both the benefits and adverse effects of this extremely popular video game. Benefits include increased exercise, socialization, and outdoor activity. Negative effects include increased risk of injury, abduction, trespassing, violence, and cost.

Pediatricians play a key role in counseling parents and children about safety precautions and setting appropriate limits for impressionable youth. Parents and pediatricians should be aware of this new and remarkably popular game that appeals to a wide variety of individuals. To protect children from injury, predators, and inappropriate situations, parents and pediatricians must regulate children's participation in this game and maintain vigilance for potentially dangerous circumstances.
Prevalence and Significance of Autoantibodies in Children With Acute Liver Failure
Authors: Narkewicz Michael R. , Horslen Simon , Belle Steven H. , Rudnick David A. , Ng Vicky L. , Rosenthal Philip , Romero Rene , Loomes Kathleen M. , Zhang Song , Hardison Regina M. , Squires Robert H. ,   Pediatric Acute Liver Failure Study Group
Published: August 2016

Objectives:

The purpose of the present study is to estimate autoantibody (auto‐AB) frequency, clinical characteristics, and 21‐day outcome of participants in the Pediatric Acute Liver Failure Study Group (PALFSG) by antinuclear antibody, smooth muscle antibody, and liver‐kidney microsomal (LKM) antibody status.

Methods:

Auto‐ABs were determined at local and/or central laboratories. Subjects were assigned to autoimmune hepatitis (AIH), indeterminate, and other diagnoses groups.

Results:

Between 1999 and 2010, 986 subjects were enrolled in the PALFSG. At least 1 auto‐AB result was available for 722 (73.2%). At least 1 auto‐AB was positive for 202 (28.0%). Diagnoses for auto‐AB+ subjects were AIH (63), indeterminate (75), and other (64). Auto‐ABs were more common in Wilson disease (12/32, 37.5%) compared with other known diagnoses (52/253, 20.6%, P = 0.03). LKM+ subjects were younger (median 2.4 vs 9.1 years, P < 0.001) and more likely to undergo liver transplantation (53.3% vs 31.4% P = 0.02) than other auto‐AB+/LKM− subjects. Steroid treatment of subjects who were auto‐AB+ was not significantly associated with survival and the subgroup with known diagnoses other than AIH had a higher risk of death.

Conclusions:

Auto‐ABs are common in children with acute liver failure, occurring in 28%. Auto‐AB+ subjects have similar outcomes to auto‐AB negative subjects. LKM+ children are younger and more likely to undergo liver transplantation compared with other auto‐AB+ subjects. Although auto‐AB may indicate a treatable condition, positivity does not eliminate the need for a complete diagnostic evaluation because auto‐ABs are present in other conditions. The significance of auto‐AB in pediatric acute liver failure remains uncertain, but LKM+ appears to identify a unique population of children who merit further study.
Comparison of Nasal Potential Difference and Intestinal Current Measurements as Surrogate Markers for CFTR Function
Authors: Wilschanski Michael , Yaakov Yasmin , Omari Ibrahim , Zaman Munir , Martin Camilia R. , Cohen‐Cymberknoh Malena , Shoseyov David , Kerem Eitan , Dasilva Deborah , Sheth Sunil , Uluer Ahmet , O'Sullivan Brian P. , Freedman Steven
Published: August 2016

Objectives:

Nasal potential difference (NPD) measurement is part of the diagnostic criteria for cystic fibrosis (CF) and now used routinely as an endpoint in clinical trials of correcting the basic defect in CF. Intestinal current measurement (ICM), measured ex vivo on a rectal biopsy, has been used to study cystic fibrosis transmembrane conductance regulator (CFTR) function but has not been compared to NPD in the same subject in adults and children. The aim of the study is to evaluate the potential usefulness of ICM as a marker of CFTR function for treatment studies compared NPD in patients with CF and in healthy control subjects.

Methods:

ICM and NPD were performed on healthy controls and patients with CF. The healthy adults were individuals undergoing routine screening colonoscopy at the Beth Israel Deaconess Medical Center. The healthy children were undergoing colonoscopy for suspicion of inflammation in Hadassah Hebrew University Medical Center. The CF adults were recruited from Boston Children's Hospital CF Center and CF Center Worcester Mass, the children with CF from Hadassah CF Center.

Results:

ICM measurements in healthy control subjects (n = 16) demonstrated a mean (±SE) carbachol response of 16.0 (2.2) μA/cm2, histamine response of 13.2 (2.1) μA/cm2 and a forskolin response of 6.3 (2.0) μA/cm2. Basal NPD of −15.9 (1.9) and response to Cl− free + isoproterenol of −13.8 (2.0). These responses were inverted in CF subjects (n = 12) for ICM parameters with carbachol response of −3.0 (0.5) μA/cm2, histamine −1.0 (0.8) μA/cm2 and a forskolin response of 0.5 (0.3) and also for NPD parameters; basal NPD of −42.2 (4.3) and response to Cl− free + isoproterenol of 4.3 (0.7). Pearson correlation test showed the comparability of ICM and NPD in assessing CFTR function.

Conclusions:

ICM is equivalent to NPD in the ability to distinguish patients with CF from controls and could be used as surrogate markers of CFTR activity in treatment protocols.
Transfusion Therapy in Children With Sickle Cell Disease
Authors: Inati Adlette , Mansour Anthony G. , Sabbouh Toni , Amhez Ghid , Hachem Ahmad , Abbas Hussein A.
Published: August 2016

Hydroxyurea, blood transfusions, and hematopoietic stem cell transplantation represent the 3 disease-modifying therapies in children with sickle cell disease (SCD). Blood transfusions play an increasingly important role in both prevention and management of SCD complications in this age group. This review will focus on the indications of blood transfusion in children with SCD and modalities of its administration. It will also highlight the complications of this life-saving therapy and ways of optimizing transfusion to minimize its associated risks.
Acute Lymphoblastic Leukemia Presenting With Pancytopenia Followed by a 14-Month-Long Period of Transient Remission Possibly Supporting the Adrenal Hypothesis of Leukemogenesis
Authors: Lynggaard Line Stensig , Marquart Hanne V. , Kjeldsen Eigil , Madsen Hans O. , Hasle Henrik
Published: August 2016

A small group of children with acute lymphoblastic leukemia (ALL) have a preleukemic phase of pancytopenia followed by a period of spontaneous remission before the diagnosis (pre-ALL). A 6-year-old girl presented with pancytopenia, fever, and myelodysplasia. Following transient remission pre-B ALL was diagnosed 14 months later. Clonal B-lineage blasts at the period of pancytopenia were identified retrospectively. The interval between pre-ALL and ALL-diagnosis was longer than previously reported. The infection was clinically severe and might have induced a significant endogenous corticosteroids production resulting in the long-lasting remission. The case supports the adrenal and the Coley’s toxin hypothesis in leukemogenesis.
Psychometric Properties of the Chinese Version of the Acceptance of Chronic Health Conditions (Stoma) Scale for Patients With Stoma
Authors: Lim Siew Hoon , He Hong-Gu , Chan Sally Wai Chi
Published: August 2016

Background:

Formation of a stoma is a common outcome in surgical treatment of colorectal cancer. A higher acceptance of stoma was shown to improve quality of life of patients. No instrument in Chinese is available that can be used to measure the acceptance of stoma among patients with colorectal cancer.

Objectives:

The aims of this study were to translate and test the psychometric properties of Chinese version of Acceptance of Chronic Health Conditions (ACHC) (Stoma) scale.

Methods:

A sample of 100 Chinese-speaking patients with stoma was recruited from a public tertiary care hospital in Singapore. The scale was translated into Chinese and reviewed by an expert panel for semantic equivalence and content validity testing. Convergent validity was established by exploring correlations between scores of the Chinese version of the ACHC (Stoma) scale and those of the 5-level version of European Quality of Life Questionnaire—5 Dimensions. Reliability was assessed by internal consistency and test-retest reliability.

Results:

The newly translated scale had high content validity (content validity index = 94%) and acceptable internal consistency (Cronbach’s α = .846). The test-retest reliability was satisfactory with an intraclass coefficient of 0.997. A positive correlation was found between both scores on ACHC (Stoma) scale and EQ-5D utility score (r = 0.63, P < .01) and EQ-5D global visual analog scale (r = 0.70, P < .01).

Conclusions:

The Chinese version of the ACHC (Stoma) scale demonstrated satisfactory content validity, good convergent validity, and adequate internal consistency and stability.

Implications for Practice:

This scale can be used as a convenient screening tool in clinical settings to assess the level of acceptance in Chinese-speaking patients with stoma.
Knowledge and Beliefs Regarding Breast and Cervical Cancer Screening Among Mexican-Heritage Latinas
Authors: Szalacha Laura A. , Kue Jennifer , Menon Usha
Published: August 2016

Background:

Lower participation rates in mammography and Papanicolaou test are common among Latinas compared with other ethnic groups. Suboptimal screening rates are attributed to lack of knowledge, access to services, and cultural influences.

Objective:

The purpose of this study is to qualitatively examine an alternative framework for examining cultural influences on Mexican-heritage Latinas’ understandings of breast and cervical cancer screening and how to leverage their beliefs to positively influence screening practices.

Methods:

The study is based on the analysis of 4 focus groups with 47 Latinas residing in greater Phoenix, Arizona.

Results:

Iterative qualitative analyses identified 5 major themes: (1) knowledge and beliefs about cancer cause and risk in general, (2) knowledge and beliefs specific to breast and cervical cancer screening, (3) experiences with breast and cervical cancer screening, (4) facilitators and barriers to breast and cervical screening, and (5) desired information about cancer and screening.

Conclusions:

Rather than focusing on Latinas’ knowledge and/or misconceptions of breast and cervical cancer in screening-related education, researchers must examine what Latinas believe and leverage those convictions to expand their perceptions and behaviors related to breast and cervical cancer prevention practices.

Implications for Practice:

Practitioners should recognize that Latinas may differ in beliefs from other minorities, and that even within-group, there may be cultural differences that influence cancer screening behaviors.
Development of Indicators to Measure Health Literate Discharge Practices
Authors: Innis Jennifer , Barnsley Jan , Berta Whitney , Daniel Imtiaz
Published: August 2016

Health literate discharge practices meet the health literacy needs of patients and families at the time of hospital discharge and are associated with improved patient outcomes and reduced readmission. A Delphi panel consisting of nurses, other health care providers, and researchers was used to develop a set of indicators of health literate discharge practices based on the practices of Project RED (Re-Engineered Discharge). These indicators can be used to measure and monitor the use of health literate discharge practices.
Sensory Gating Deficits in First-Episode Psychosis
Authors: Morales-Muñoz Isabel , Jurado-Barba Rosa , Fernández-Guinea Sara , Rodríguez-Jiménez Roberto , Jiménez-Arriero Miguel Ángel , Criado José R. , Rubio Gabriel
Published: August 2016

Sensory gating deficits are commonly found in patients with schizophrenia. However, there is still scarce research on this issue. Thirty-eight patients with first-episode psychosis (FEP) were compared to thirty-eight controls. A condition-test paradigm of event-related potentials (ERP), prepulse inhibition (PPI), and some specific tasks of the MATRICS Consensus Cognitive Battery (MCCB) were used (i.e., TMT, BACS-SC, and Fluency for processing speed and CPT-IP for attention and vigilance). The ERP components measured were P50, N1, and P2. The PPI intervals examined were 30, 60, and 120 msec. Regarding the MCCB, processing speed and attention/vigilance cognitive domains were selected. FEP patients showed significant deficits in N1 and P2 components, at 30 and 60 PPI levels and in all the MCCB subtests selected. We obtained significant relationships in N1 with PPI-60, and with one MCCB subtest for processing speed. In addition, this same subtest showed significant association with P2. Therefore, sensory gating functioning is widely impaired since the very early stages of schizophrenia.
Content Validation of a Quality and Safety Education for Nurses–Based Clinical Evaluation Instrument
Authors: Altmiller Gerry
Published: August 2016

Quality and Safety Education for Nurses (QSEN) has been prominent in nursing education for 10 years. Since its inception, faculty have used the QSEN competencies as a framework for developing teaching strategies and tools, but there are few findings available to support this practice. This article describes the process of developing a QSEN-based clinical evaluation instrument for a prelicensure nursing program and establishing content validation for its items using the content validity index.
In Vivo Angiography Quantifies Oxygen-Induced Retinopathy Vascular Recovery
Authors: Mezu-Ndubuisi Olachi J.
Published: August 2016

Purpose

Retinopathy of prematurity (ROP) is a potentially blinding vasoproliferative disease. There is no standardized way to quantify plus disease (tortuous and dilated retinal vessels) or characterize abnormal recovery during ROP monitoring. This study objectively studies vascular features in live mice during development using noninvasive retinal imaging.

Methods

Using fluorescein angiography (FA), retinal vascular features were quantified in live mice with oxygen induced retinopathy (OIR). A total of 105 wild-type mice were exposed to 77% oxygen from postnatal day 7 (P7) till P12 (OIR mice). Also, 105 age-matched pups were raised in room air (RA mice). In vivo FA was performed at early (P16 to P20), mid (P23 to P27), late (P30 to P34), and mature (P47) phases of retinal vascular development. Retinal vascular area, retinal vein width, and retinal artery tortuosity were quantified.

Results

Retinal artery tortuosity was higher in OIR than RA mice at early (p < 0.0001), mid (p < 0.0001), late (p < 0.0001), and mature (p < 0.0001) phases. Retinal vascular area in OIR mice increased from early to mid-phase (p < 0.0001), but remained unchanged from mid to late (p = 0.23), and from late to mature phase (p = 0.98). Retinal vein width was larger in OIR mice compared to RA mice during early phase only. Arteries in OIR mice were more tortuous from early to mid-phase (p < 0.0001), but tortuosity remained stable from mid through mature phase. RA mice had an increase in retinal vascular area from early to late phase, but maintained uniform retinal vein width and retinal artery tortuosity in all phases.

Conclusions

In vivo FA distinguished arterial and venous features, similar to plus disease, and revealed aberrant recovery of OIR mice (arterial tortuosity, reduced capillary density, and absent neovascular buds) that persisted into adulthood. Retinal artery tortuosity may be a reliable, objective marker of severity of ROP. Infants with abnormal retinal vascular recovery may need extended monitoring.
Type II Macular Telangiectasia Presenting as Bilateral Retinochoroidal Anastomosis
Authors: Agarwal Aniruddha , Invernizzi Alessandro , Kumari Neha , Singh Ramandeep
Published: August 2016

Purpose

Retinochoroidal anastamosis (RCA) is known to be associated with retinal angiomatous proliferans rather than idiopathic macular telangiectasia. The case report describes a rare association of bilateral RCA with type II idiopathic macular telangiectasia in an elderly woman.

Case Report

A 65-year-old female patient presented with decreased vision in both eyes to the ophthalmology clinic. She was diagnosed with bilateral large serous retinal pigment epithelial detachments (PED). Atypical association of PED with IMT led to additional imaging, including fluorescein angiography (FA), spectral-domain optical coherence tomography (SD-OCT), and indocyanine green angiography (ICGA). Multimodal imaging analysis revealed characteristic signs of RCA such as the so-called kissing sign on SD-OCT. The patient was not offered any treatment due to the poor prognosis associated with the condition.

Conclusions

Although more commonly associated with retinal angiomatous proliferans (type III neovascular age-related macular degeneration), RCA can present in type II IMT Stage 5.
Quantification of Estrogen Receptor Expression in Normal Breast Tissue in Postmenopausal Women With Breast Cancer and Association With Tumor Subtypes
Authors: Gulbahce H. Evin , Blair Cindy K. , Sweeney Carol , Salama Mohamed E.
Published: August 2016

Estrogen exposure is important in the pathogenesis of breast cancer and is a contributing risk factor. In this study we quantified estrogen receptor (ER) alpha expression in normal breast epithelium (NBR) in women with breast cancer and correlated it with breast cancer subtypes. Tissue microarrays were constructed from 204 breast cancer patients for whom normal breast tissue away from tumor was available. Slides stained with ER were scanned and expression in normal terminal duct lobular epithelium was quantitated using computer-assisted image analysis. ER expression in normal terminal duct lobular epithelium of postmenopausal women with breast cancer was significantly associated with estrogen and triple (estrogen, progesterone receptors, and HER2) negative phenotypes. Also increased age at diagnosis was significantly associated with ER expression in NBR. ER positivity in normal epithelium did not vary by tumor size, lymph node status, tumor grade, or stage. On the basis of quantitative image analysis, we confirm that ER expression in NBR increases with age in women with breast cancer, and report for the first time, a significant association between ER expression in NBR with ER-negative and triple-negative cancers in postmenopausal women.
The Stem Cell-associated Transcription Factor SOX2 as a Diagnostic Marker of High-grade Squamous Intraepithelial Lesion of the Uterine Cervix in Comparison With p16 and Ki-67
Authors: Wolsky Rebecca J. , Harbour Lori N. , Mirza Kamran M. , Montag Anthony G. , Gwin Katja
Published: August 2016

The transcription factor SOX2 has been identified as an oncogene involved in the pathogenesis of squamous cell carcinoma (SCC) of multiple sites, including the uterine cervix. The relationship between SOX2 overexpression and the continuum of precancerous lesions of the cervix has not been previously elucidated. We evaluated SOX2 immunohistochemical expression in normal cervix, low-grade squamous intraepithelial lesion (LSIL) (mild squamous dysplasia), high-grade squamous intraepithelial lesion (HSIL) (moderate and severe dysplasia) and SCC of the cervix in comparison with p16 and Ki-67. Staining patterns were scored as negative, basal one third of the epithelium, lower two third, or full thickness. The results showed that SOX2 expression was limited to the basal one third in 84% of LSIL cases, whereas 95% of HSIL showed SOX2 expression up to two third or full thickness (P<0.0001). p16 and Ki-67 displayed similar results. The difference in SOX2 expression between moderate and severe dysplasia was not statistically significant (P=0.53). Invasive SCC positivity was as follows: SOX2 94%; p16 89%; and Ki-67 100%. Our findings support a role for SOX2 in the progression of squamous dysplasia to SCC. The Lower Anogenital Standardization Terminology Project’s recent assertion of a lack of a biological correlate to cervical intraepithelial neoplasia II is also upheld by SOX2. For equivocal situations in which a diagnosis of cervical intraepithelial neoplasia II would have been made, Lower Anogenital Standardization Terminology recommends p16, or other biomarkers such as Ki-67 to clarify the diagnosis. SOX2, with a clean nuclear staining pattern, may also be suitable for this role.
Pulmonary Hypertension
Authors: Oishi Peter , Fineman Jeffrey R.
Published: August 2016

Objectives:

To review the clinical classification, diagnosis, and pathophysiology of pulmonary hypertension in children, emphasizing the role of right ventricular function, ventricular interaction, and congenital heart disease in the evolution and progression of disease, as well as management strategies and therapeutic options.

Data Source:

MEDLINE, PubMed.

Conclusions:

Critically ill children with pulmonary hypertension associated with congenital heart disease are a high-risk population. Congenital cardiac defects resulting in either increased pulmonary blood flow or impaired pulmonary venous drainage predispose patients to developing structural and functional aberrations of the pulmonary vasculature. Mortality from pulmonary hypertension is most directly related to right ventricular failure.
Hemodynamic Monitoring
Authors: Bronicki Ronald A.
Published: August 2016

Objectives:

In this review, we discuss hemodynamic monitoring modalities, including their application, the interpretation of data, limitations, and impact on outcomes.

Data Source:

MEDLINE, PubMed.

Conclusions:

One of the tenets of critical care medicine is to ensure adequate tissue oxygenation. This assessment must be timely and accurate to optimize outcomes. The clinical assessment of cardiac function, cardiac output, and tissue oxygenation based on the physical examination and standard hemodynamic variables, although an indispensable part of this exercise, has significant limitations. The use of adjunctive hemodynamic monitoring modalities provides a much more objective, accurate, and timely assessment of the patient’s hemodynamic profile and is invaluable for assessing the patient’s clinical status, clinical trajectory, and response to interventions.
Acquired and Congenital Coronary Artery Diseases
Authors: Fuller Stephanie , Ravishankar Chitra
Published: August 2016

Objectives:

The objectives of this review are to discuss the spectrum of coronary artery anomalies and the evidence behind current treatment strategies.

Data Source:

MEDLINE and PubMed.

Conclusion:

Coronary artery anomalies exist in up to 1% of the population and most of these do not cause symptoms or ischemia and do not require any surgical intervention whereas others are potentially fatal. The type of surgical intervention is often dictated by the type of lesion, and upon the unique anatomic and physiologic variables associated with each lesion. Postoperative care can be challenging particularly after surgical repair of anomalous left coronary artery from the pulmonary artery.
Arrhythmias in Cardiac Critical Care
Authors: Smith Andrew H.
Published: August 2016

Objectives:

Here, we characterize the frequency, mechanisms, clinical impact, and potential treatment options for several arrhythmias commonly encountered in pediatric cardiac critical care.

Data Source:

MEDLINE and PubMed.

Conclusions:

Arrhythmias among children in the cardiac critical care setting are common and clinically important, associated independently with prolonged mechanical ventilation, critical care unit stay, and an increase in mortality. The precise characterization of an arrhythmia may provide clues as to an underlying mechanism as well as serve to guide treatment. Arrhythmia therapy, pharmacologic or otherwise, is directed toward addressing the underlying mechanism, and as such may be applicable to the treatment of more than one specific rhythm disturbance. Decisions concerning therapy must call into consideration an arrhythmia’s underlying etiology, mechanism, and associated hemodynamic embarrassment, along with the potential for adverse effects of treatment.
Acute Kidney Injury and Cardiorenal Syndromes in Pediatric Cardiac Intensive Care
Authors: Cooper David S. , Kwiatkowski David M. , Goldstein Stuart L. , Krawczeski Catherine D.
Published: August 2016

Objectives:

The objectives of this review are to discuss the definition, diagnosis, and pathophysiology of acute kidney injury and its impact on immediate, short-, and long-term outcomes. In addition, the spectrum of cardiorenal syndromes will be reviewed including the pathophysiology on this interaction and its impact on outcomes.

Data Source:

MEDLINE and PubMed.

Conclusion:

The field of cardiac intensive care continues to advance in tandem with congenital heart surgery. As mortality has become a rare occurrence, the focus of cardiac intensive care has shifted to that of morbidity reduction. Acute kidney injury adversely impact outcomes of patients following surgery for congenital heart disease as well as in those with heart failure (cardiorenal syndrome). Patients who become fluid overloaded and/or require dialysis are at a higher risk of mortality, but even minor degrees of acute kidney injury portend a significant increase in mortality and morbidity. Clinicians continue to seek methods of early diagnosis and risk stratification of acute kidney injury to prevent its adverse sequelae.
Clinical-Physiological Considerations in Patients Undergoing Staged Palliation for a Functionally Single Ventricle
Authors: Penny Daniel J. , Krishnamurthy Rajesh
Published: August 2016

Objectives:

The objectives of this review are to discuss the pathophysiology of the circulation with a functionally univentricular heart, with a focus on the unique physiologic characteristics, which provide the underpinnings for the management of these complex patients.

Data Source:

MEDLINE and PubMed.

Conclusions:

The circulation of the patient with a functionally univentricular heart displays unique physiologic characteristics, which are quite different from those of the normal biventricular circulation. There are profound differences within the heart itself in terms of ventricular function, interventricular interactions, and myocardial architecture, which are likely to have significant implications for the efficiency of ventricular ejection and metabolism. The coupling between the systemic ventricle and the aorta also displays unique features. The 3D orientation of the Fontan anastomosis itself can profoundly impact cardiac output, although the “portal” pulmonary arterial bed is a crucial determinant of overall cardiovascular function. As a result, disease-specific approaches to improve cardiovascular function are required at all stages during the care of these complex patients.
Shunt Lesions Part II: Anomalous Pulmonary Venous Connections and Truncus Arteriosus
Authors: Martin Billie-Jean , Karamlou Tara B. , Tabbutt Sarah
Published: August 2016

Objectives:

The objectives of this review are to describe the anatomy, pathophysiology, perioperative therapeutic strategies, and operative procedures for patients with anomalous pulmonary venous connections and truncus arteriosus.

Data Source:

MEDLINE and PubMed.

Conclusions:

An understanding of the anatomy and pathophysiology of anomalous pulmonary venous connections and truncus arteriosus is essential for the optimal perioperative management of these complex and challenging congenital lesions.
L-Transposition of the Great Arteries
Authors: Ravishankar Chitra
Published: August 2016

Objectives:

To describe the various surgical options, perioperative management strategies, and outcomes for this complex lesion.

Data Source:

MEDLINE and PubMed.

Conclusions:

L-transposition of the great arteries is a relatively rare defect, comprising less than 1% of all congenital heart defects. There is considerable heterogeneity in clinical presentation depending on the presence of associated defects. Surgery for this rare and complex defect has evolved from “physiologic” repair in which the right ventricle remains in the systemic position to the “anatomic” repair, which restores the left ventricle as the systemic ventricle. There has been a great interest in performing the anatomic repair or “double switch” operation, a rather complex operation that presents unique challenges in the postoperative period.
Aortic and Mitral Valve Disease and Left Ventricular Dysfunction in Children
Authors: Maher Kevin O. , Tweddell James S.
Published: August 2016

Objectives:

In this review, we will discuss aortic stenosis, aortic regurgitation, mitral regurgitation, and mitral stenosis. We will review the etiology, anatomy, pathophysiology, presentation, and treatment of aortic and mitral valve disease. Age and lesion specific treatments are outlined based on the severity of valve disease with an aim at long-term preservation of left ventricular function.

Data Source:

MEDLINE and PubMed.

Conclusions:

Mitral and aortic valve disease leads to unique hemodynamic burdens that can impact left ventricular function, quality of life, and longevity. The primary challenge in the management of mitral and aortic valve disease is to apply appropriate medical management and identify that point in time at which the surgery is necessary. Although guidelines have been established for the management of aortic and mitral valve disease in adults, the challenges of early presentation, maintenance of growth potential, and apparent increased tolerance of hemodynamic burden in children makes decision making challenging.
Clinical Impact of Accurate Point-of-Care Glucose Monitoring for Tight Glycemic Control in Severely Burned Children*
Authors: Tran Nam K. , Godwin Zachary R. , Steele Amanda N. , Wolf Steven E. , Palmieri Tina L.
Published: August 2016

Objectives:

The goal of this study was to retrospectively evaluate the clinical impact of an accurate autocorrecting blood glucose monitoring system in children with severe burns. Blood glucose monitoring system accuracy is essential for providing appropriate intensive insulin therapy and achieving tight glycemic control in critically ill patients. Unfortunately, few comparison studies have been performed to evaluate the clinical impact of accurate blood glucose monitoring system monitoring in the high-risk pediatric burn population.

Design:

Retrospective analysis of an electronic health record system.

Setting:

Pediatric burn ICU at an academic medical center.

Patients:

Children (aged < 18 yr) with severe burns (≥ 20% total body surface area) receiving intensive insulin therapy guided by either a noncorrecting (blood glucose monitoring system-1) or an autocorrecting blood glucose monitoring system (blood glucose monitoring system-2).

Measurements and Main Results:

Patient demographics, insulin rates, and blood glucose monitoring system measurements were collected. The frequency of hypoglycemia and glycemic variability was compared between the two blood glucose monitoring system groups. A total of 122 patient charts from 2001 to 2014 were reviewed. Sixty-three patients received intensive insulin therapy using blood glucose monitoring system-1 and 59 via blood glucose monitoring system-2. Patient demographics were similar between the two groups. Mean insulin infusion rates (5.1 ± 3.8 U/hr; n = 535 paired measurements vs 2.4 ± 1.3 U/hr; n = 511 paired measurements; p < 0.001), glycemic variability, and frequency of hypoglycemic events (90 vs 12; p < 0.001) were significantly higher in blood glucose monitoring system-1–treated patients. Compared with laboratory measurements, blood glucose monitoring system-2 yielded the most accurate results (mean ± sd bias: –1.7 ± 6.9 mg/dL [–0.09 ± 0.4 mmol/L] vs 7.4 ± 13.5 mg/dL [0.4 ± 0.7 mmol/L]). Blood glucose monitoring system-2 patients achieve glycemic control more quickly (5.7 ± 4.3 vs 13.1 ± 6.9 hr; p< 0.001) and stayed within the target glycemic control range longer compared with blood glucose monitoring system-1 patients (85.2% ± 13.9% vs 57.9% ± 29.1%; p < 0.001).

Conclusions:

Accurate autocorrecting blood glucose monitoring system optimizes intensive insulin therapy, improves tight glycemic control, and reduces the risk of hypoglycemia and glycemic variability. The use of an autocorrecting blood glucose monitoring system for intensive insulin therapy may improve glycemic control in severely burned children.
Platelet Transfusions in Pediatric Intensive Care*
Authors: Du Pont-Thibodeau Geneviève , Tucci Marisa , Robitaille Nancy , Ducruet Thierry , Lacroix Jacques
Published: August 2016

Objectives:

To characterize the determinants of platelet transfusion in a PICU and determine whether there exists an association between platelet transfusion and adverse outcomes.

Design:

Prospective observational single center study, combined with a self-administered survey.

Setting:

PICU of Sainte-Justine Hospital, a university-affiliated tertiary care institution.

Patients:

All children admitted to the PICU from April 2009 to April 2010.

Intervention:

None.

Measurements and Main Results:

Among 842 consecutive PICU admissions, 60 patients (7.1%) received at least one platelet transfusion while in PICU. In the univariate analysis, significant determinants for platelet transfusion were admission Pediatric Risk of Mortality Score greater than 10 (odds ratio, 6.80; 95% CI, 2.5–18.3; p < 0.01) and Pediatric Logistic Organ Dysfunction scores greater than 20 (odds ratio, 26.9; 95% CI, 8.88–81.5; p < 0.01), history of malignancy (odds ratio, 5.08; 95% CI, 2.43–10.68; p < 0.01), thrombocytopenia (platelet count, < 50 × 109/L or < 50,000/mm3) (odds ratio, 141; 95% CI, 50.4–394.5; p < 0.01), use of heparin (odds ratio, 3.03; 95% CI, 1.40–6.37; p < 0.01), shock (odds ratio, 5.73; 95% CI, 2.85–11.5; p < 0.01), and multiple organ dysfunction syndrome (odds ratio, 10.41; 95% CI, 5.89–10.40; p < 0.01). In the multivariate analysis, platelet count less than 50 × 109/L (odds ratio, 138; 95% CI, 42.6–449; p < 0.01) and age less than 12 months (odds ratio, 3.06; 95% CI, 1.03–9.10; p = 0.02) remained statistically significant determinants. The attending physicians were asked why they gave a platelet transfusion; the most frequent justification was prophylactic platelet transfusion in presence of thrombocytopenia with an average pretransfusion platelet count of 32 ± 27 × 109/L (median, 21), followed by active bleeding with an average pretransfusion platelet count of 76 ± 39 × 109/L (median, 72). Platelet transfusions were associated with the subsequent development of multiple organ dysfunction syndrome (odds ratio, 2.53; 95% CI, 1.18–5.43; p = 0.03) and mortality (odds ratio, 10.1; 95% CI, 4.48–22.7; p < 0.01).

Conclusions:

Among children, 7.1% received at least one platelet transfusion while in PICU. Thrombocytopenia and active bleeding were significant determinants of platelet transfusion. Platelet transfusions were associated with the development of multiple organ dysfunction syndrome and increased mortality.
Refractory Status Epilepticus in Children: Intention to Treat With Continuous Infusions of Midazolam and Pentobarbital*
Authors: Tasker Robert C. , Goodkin Howard P. , Sánchez Fernández Iván , Chapman Kevin E. , Abend Nicholas S. , Arya Ravindra , Brenton James N. , Carpenter Jessica L. , Gaillard William D. , Glauser Tracy A. , Goldstein Joshua , Helseth Ashley R. , Jackson Michele C. , Kapur Kush , Mikati Mohamad A. , Peariso Katrina , Wainwright Mark S. , Wilfong Angus A. , Williams Korwyn , Loddenkemper Tobias
Published: August 2016

Objective:

To describe pediatric patients with convulsive refractory status epilepticus in whom there is intention to use an IV anesthetic for seizure control.

Design:

Two-year prospective observational study evaluating patients (age range, 1 mo to 21 yr) with refractory status epilepticus not responding to two antiepileptic drug classes and treated with continuous infusion of anesthetic agent.

Setting:

Nine pediatric hospitals in the United States.

Patients:

In a cohort of 111 patients with refractory status epilepticus (median age, 3.7 yr; 50% male), 54 (49%) underwent continuous infusion of anesthetic treatment.

Main Results:

The median (interquartile range) ICU length of stay was 10 (3–20) days. Up to four “cycles” of serial anesthetic therapy were used, and seizure termination was achieved in 94% by the second cycle. Seizure duration in controlled patients was 5.9 (1.9–34) hours for the first cycle and longer when a second cycle was required (30 [4–120] hr; p = 0.048). Midazolam was the most frequent first-line anesthetic agent (78%); pentobarbital was the most frequently used second-line agent after midazolam failure (82%). An electroencephalographic endpoint was used in over half of the patients; higher midazolam dosing was used with a burst suppression endpoint. In midazolam nonresponders, transition to a second agent occurred after a median of 1 day. Most patients (94%) experienced seizure termination with these two therapies.

Conclusions:

Midazolam and pentobarbital remain the mainstay of continuous infusion therapy for refractory status epilepticus in the pediatric patient. The majority of patients experience seizure termination within a median of 30 hours. These data have implications for the design and feasibility of future intervention trials. That is, testing a new anesthetic anticonvulsant after failure of both midazolam and pentobarbital is unlikely to be feasible in a pediatric study, whereas a decision to test an alternative to pentobarbital, after midazolam failure, may be possible in a multicenter multinational study.
Diagnosis of Cystic Teratoma Facilitated by Point-of-Care Ultrasonography
Authors: Horner Kimberly Bogard , Marin Jennifer R.
Published: August 2016

Abdominal pain and constipation are common chief complaints in the pediatric emergency department. We present a case of a child with pain, abdominal distention, and constipation ultimately diagnosed with an ovarian teratoma and the role of point-of-care ultrasonography in the evaluation.
Pediatric Obesity: Is There Room for Active Video Games in Prevention or Management?
Authors: Thivel David , O'Malley Grace
Published: August 2016

Children and adolescents spend a considerable amount of time engaged in sedentary behaviors that have been shown to favor weight gain and impaired physical fitness. Active video games have been proposed to increase physical activity levels. Although active video games may offer an interesting alternative to reducing sedentary time for children, the present commentary aimed to determine whether there is adequate evidence that compared active video gaming to real-life play and exercise. Given the dearth of data, it is not possible at present to support the use of active video games as substitutes for traditional forms of active play and health-enhancing physical activity. Further research should be encouraged and therapists should not consider active video games exclusively for intervention in children with obesity.
Tobacco User Characteristics and Outcomes Related to Intensity of Quitline Program Use: Results From Minnesota and Pennsylvania
Authors: Lien Rebecca K. , Schillo Barbara A. , Mast Jay L. , Lukowski Amy V. , Greenseid Lija O. , Keith Jennifer D. , Keller Paula A.
Published: August 2016

Context:

Tobacco users in all 50 states have access to quitline telephone counseling and cessation medications. While studies show multiple calls relate to quit success, most participants do not complete a full call series. To date, quitline program use studies have analyzed single factors—such as number of calls or counseling minutes.

Objective:

This study combines multiple factors of quitline program use across 2 states to describe how participants use a 5-call program; assess whether intensity of program use is associated with participant subgroups; and assess whether key outcomes (quitting, satisfaction) are associated with intensity.

Design, Setting, and Participants:

This observational study examines data for quitline participants in Minnesota (n = 2844) and Pennsylvania (n = 14 359) in 2011 and 2012. A subset of participants was surveyed 7 months after registration to assess key outcomes (response rates: Minnesota 65%; Pennsylvania 60%).

Main Outcome Measures:

Quitline utilization data were used to identify program use variables: nicotine replacement therapy provision, number of counseling calls, number of counseling minutes, days from first to last counseling call, and days from registration to first counseling call. Ten program use groups were created using all 5 program use variables, from lowest (1) to highest (10) intensity.

Results:

Results were similar for both states. Only 11% of Minnesota and 8% of Pennsylvania participants completed all 5 calls. Intensity of quitline program use was associated with several participant characteristics including health conditions and age. Both quit status and program satisfaction were associated with program use intensity. Quit rates peaked in group 9, participants who received the full 5-call program.

Conclusions:

Quitlines should focus on engaging participants in multiple calls to improve quit outcomes. In addition, it is important to leverage multiple program use factors for a fuller understanding of how quitline participants use a program.
Management of Complications Caused by Permanent Fillers in the Face: A Treatment Algorithm
Authors: Cassuto Daniel , Pignatti Marco , Pacchioni Lucrezia , Boscaini Giulia , Spaggiari Antonio , De Santis Giorgio
Published: August 2016

Background:

Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. Inflammatory reactions (often termed granulomas) to these materials can be functionally and socially disabling. Most therapeutic options used until now are nonspecific antiinflammatory treatments, targeting an ill-defined immune reaction of undefined cause. The minimally invasive intralesional laser treatment can remove the foreign substance and the inflammatory reaction with an 808-nm diode laser.

Methods:

Two hundred nineteen consecutive patients referred from September of 2006 until June of 2013 for inflammatory reactions to permanent facial fillers and treated with this technique at the authors’ institution with a minimum 6-month follow-up were studied. All patients were screened with an ultrasound soft-tissue examination and the lesions were classified as either cystic (implants inserted by bolus injections) or infiltrating (as in microdeposit injection). The authors’ therapeutic approach is summarized in an algorithm: infiltrating patterns were treated with intralesional laser treatment alone, whereas cystic distribution cases were also drained through stab wound incisions. The mean patient age was 49 years (range, 23 to 72 years); 204 patients were women.

Results:

Partial improvement was obtained in 30 percent of patients, whereas 8 percent discontinued the treatment because of a lack of satisfaction. Lesions disappeared completely in 62 percent. Complications included transient swelling in all cases, hematoma in 2 percent, secondary sterile abscess in 9.5 percent, and minimal scarring in 10 percent.

Conclusion:

A problem-oriented systematic approach to inflammatory complications from permanent fillers is proposed, based on the comprehensive work from the past 7 years, with an overall improvement rate of 92 percent.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Methicillin-Resistant Staphylococcus aureus Infections: A Comprehensive Review and a Plastic Surgeon’s Approach to the Occult Sites
Authors: Hunter Cedric , Rosenfield Lorne , Silverstein Elena , Petrou-Zeniou Panayiota
Published: August 2016

Background:

Up to 20 percent of the general population is persistently colonized with Staphylococcus aureus, and 1 to 3 percent of the population is colonized with community-acquired methicillin-resistant S. aureus. Currently, the knowledge of methicillin-resistant Staphylococcus aureus carriage sites other than the nose, and their effect on surgical site infections in cosmetic surgery, is lacking.

Methods:

A comprehensive literature review using the PubMed database to analyze prevalence, anatomical carrier sites, current screening and decontamination protocols and guidelines, and methicillin-resistant S. aureus in cosmetic surgery was performed. The senior author’s (L.R.) methicillin-resistant S. aureus infection experience and prevention protocols were also reviewed.

Results:

Nasal swabs detect only 50.5 percent of methicillin-resistant S. aureus colonization, and broad screening has noted the presence of methicillin-resistant S. aureus in the ear canal and umbilicus. Decolonization protocols within the orthopedic and cardiothoracic surgery literature have reduced rates of methicillin-resistant S. aureus surgical-site infections. There are no decolonization guidelines for plastic surgeons. Since instituting their decolonization protocol, the authors have had no cases of methicillin-resistant S. aureus infection in nearly 1000 cosmetic surgery procedures.

Conclusions:

There are very limited, if any, Level I or II data regarding methicillin-resistant S. aureus screening and decolonization. As the sequelae of a surgical-site infection can be disastrous, expert opinions recommend that plastic surgeons vigorously address methicillin-resistant S. aureus colonization and infection. The authors have developed and recommend a simple decolonization protocol that includes treatment of the umbilicus, ear canal, and nares to limit surgical-site infection and improve surgical outcomes.