bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors Associated With Bleeding Secondary to Rupture of Esophageal Varices in Children and Adolescents With Cirrhosis
Authors: Pimenta Júlio R. , Ferreira Alexandre R. , Fagundes Eleonora D.T. , Queiroz Thaís C.N. , Baptista Regiane A.N. , de Araújo Moreira Eduardo G. , de Resende Camilo B. , Bittencourt Paulo F.S. , Carvalho Simone D. , Neto José A.F. , Penna Francisco J.
Published: August 2016

Objective:

Bleeding of esophageal varices is the main cause of morbidity and mortality in children with portal hypertension. It is important to understand the factors related with a bleeding episode to evaluate more effective primary prophylaxis. The present study aims to describe the endoscopic and laboratory findings associated with upper gastrointestinal bleeding (UGIB) secondary to esophageal varices.

Method:

A cross‐sectional study with 103 children and adolescents with cirrhosis, divided into a group that had experienced an episode of upper UGIB (35 patients) and a group without a history of UGIB (68 patients), was carried out. The esophageal and gastric varices were classified, and the portal hypertensive gastropathy, laboratory findings, and Child‐Pugh classification were measured.

Results:

Factors observed in univariate analysis to be associated with UGIB were the presence of esophageal varices of medium caliber or larger, portal hypertensive gastropathy, presence of red spots on esophageal varices, Child‐Pugh class B or C, and hypoalbuminemia (P < 0.05). After multivariate logistic regression analysis, the significant factors were the presence of red spots on esophageal varices and the presence of gastric varices. When separated the autoimmune hepatitis, nonbiliary atresia patients (all patients except the patients with biliary atresia), and biliary atresia groups the findings in the univariate analysis were the presence of esophageal varices of medium or larger caliber, presence of red spots on varices, and presence of gastric varices in the autoimmune hepatitis patients and nonbiliary atresia patients and presence of red spots on esophageal varices, presence of gastric varices, and Child‐Pugh classification B or C in biliary atresia group (P < 0.05). After multivariate logistic regression analysis, no statistical significance was found for any factor analyzed in any groups.

Conclusions:

The presence of gastric varices and red spots on esophageal varices were related to episodes of UGIB secondary to rupture of esophageal varices. When these findings are observed, indications for endoscopic primary prophylaxis should be evaluated. More studies are, however, necessary to better understand this problem.
The self-perception of dyspnoea threshold during the 6-min walk test: a good alternative to estimate the ventilatory threshold in chronic obstructive pulmonary disease
Authors: Couillard Annabelle , Tremey Emilie , Prefaut Christian , Varray Alain , Heraud Nelly
Published: August 2016

To determine and/or adjust exercise training intensity for patients when the cardiopulmonary exercise test is not accessible, the determination of dyspnoea threshold (defined as the onset of self-perceived breathing discomfort) during the 6-min walk test (6MWT) could be a good alternative. The aim of this study was to evaluate the feasibility and reproducibility of self-perceived dyspnoea threshold and to determine whether a useful equation to estimate ventilatory threshold from self-perceived dyspnoea threshold could be derived. A total of 82 patients were included and performed two 6MWTs, during which they raised a hand to signal self-perceived dyspnoea threshold. The reproducibility in terms of heart rate (HR) was analysed. On a subsample of patients (n=27), a stepwise regression analysis was carried out to obtain a predictive equation of HR at ventilatory threshold measured during a cardiopulmonary exercise test estimated from HR at self-perceived dyspnoea threshold, age and forced expiratory volume in 1 s. Overall, 80% of patients could identify self-perceived dyspnoea threshold during the 6MWT. Self-perceived dyspnoea threshold was reproducibly expressed in HR (coefficient of variation=2.8%). A stepwise regression analysis enabled estimation of HR at ventilatory threshold from HR at self-perceived dyspnoea threshold, age and forced expiratory volume in 1 s (adjusted r=0.79, r
2=0.63, and relative standard deviation=9.8 bpm). This study shows that a majority of patients with chronic obstructive pulmonary disease can identify a self-perceived dyspnoea threshold during the 6MWT. This HR at the dyspnoea threshold is highly reproducible and enable estimation of the HR at the ventilatory threshold.
Symptom Clusters and Impact of Fatigue and Sleep Disturbance on Symptom Experiences of Hepatoma Patients in Taiwan
Authors: Chung Meng-Hua , Wang Shu-Yi , Lin Chia-Chin
Published: August 2016

Background:

Hepatoma is the second leading cause of cancer mortality among patients with cancer in Taiwan. Patients with cancer simultaneously experience multiple symptoms in clusters. Relevant studies have generally focused on a single hepatoma symptom.

Objectives:

The aim of this study is to explore the prevalence of symptom clusters and the impact of fatigue and sleep on symptom experiences of patients with hepatoma.

Methods:

The Taiwanese version of the M.D. Anderson Symptom Inventory was administered to a sample of 100 patients. Data were analyzed using descriptive statistics, Pearson correlation, and regression, factor, and hierarchical cluster analyses.

Results:

The results showed that fatigue and sleep disturbance were the most severe symptoms experienced by patients with hepatoma. Patients with hepatoma who concurrently experienced fatigue and sleep disturbance experienced more symptoms and more severe symptoms than did those who experienced either symptom or no symptom. This study identified 2 clusters: 1 cluster comprised 8 symptoms and the other cluster comprised 5 symptoms. Factor analysis revealed the following 3 factors: pain-, gastrointestinal-, and sensation-related symptoms.

Conclusions:

Patients with hepatoma who concurrently experienced fatigue and sleep disturbance experienced more symptoms and more severe symptoms than did those who experienced either symptom or no symptom. This study identified 2 clusters experienced by patients with hepatoma.

Implications for Practice:

Our results provide implications for further research on managing the most common co-occurring symptoms to reduce symptom clusters and improve the quality of life of hepatoma patients.
Stopping the Slide
Authors: Davis Kermit G. , Kotowski Susan E. , Coombs Matthew T.
Published: August 2016

Patient migration, or the amount of movement toward the foot of the bed, has been shown to significantly vary because of the mechanical design differences in hospital beds. Previously, the amount of migration was measured immediately following head-of-bed articulation in healthy subjects. This study not only evaluates how much migration occurs immediately after head-of-bed articulation but also measures additional migration during a standard 2-hour repositioning period in subjects with limited mobility.
Improving Infusion Pump Safety Through Usability Testing
Authors: Miller Kristen E. , Arnold Ryan , Capan Muge , Campbell Michele , Zern Susan Coffey , Dressler Robert , Duru Ozioma O. , Ebbert Gwen , Jackson Eric , Learish John , Strauss Danielle , Wu Pan , Bennett Dean A.
Published: August 2016

With the recognition that the introduction of new technology causes changes in workflow and may introduce new errors to the system, usability testing was performed to provide data on nursing practice and interaction with infusion pump technology. Usability testing provides the opportunity to detect and analyze potentially dangerous problems with the design of infusion pumps that could cause or allow avoidable errors. This work will reduce preventable harm through the optimization of health care delivery.
Advanced Practice Nurse-Led Statewide Collaborative to Reduce Falls in Hospitals
Authors: Gray-Miceli Deanna , Mazzia Lisa , Crane Giles
Published: August 2016

Thirty-eight hospitals participated in falls prevention team training, followed by coaching and mentoring over 3 months to develop unit-based initiatives to reduce falls. Initiatives centered on fall risk assessment, rounding, or postfall assessment. Paired t test of the pre-/postintervention fall rates of 23 of the hospitals revealed reduced fall rates (P < .01). The estimated mean decrease was 1.7 falls per 1000 patient days (95% confidence limits of 0.7-2.7).
The Baptist Health High-Risk Falls Assessment
Authors: Bugajski Andrew , Lengerich Alex , McCowan Denise , Merritt Sharon , Moe Krista , Hall Brittany , Nelson Debbie , Brockopp Dorothy
Published: August 2016

Assessing high risk for falling among psychiatric inpatients is particularly challenging in that assessments with strong sensitivity and specificity are not available. The purpose of this study was to determine the sensitivity, specificity, and diagnostic odds ratio of the Baptist Health High Risk Falls Assessment (BHHRFA), a medical-surgical fall risk assessment, in a psychiatric inpatient population. Data collected on 5910 psychiatric inpatients using the BHHRFA showed acceptable sensitivity, specificity, and diagnostic odds ratio (0.68/0.70/4.964).
Integrative Therapies for Women with a High Risk Pregnancy During Antepartum Hospitalization
Authors: Schlegel Merry L. , Whalen Jeanne L. , Williamsen Pilar M.
Published: August 2016

Background:

High-risk pregnancies that require lengthy hospitalization can cause anxiety and stress for pregnant women. Integrative medicine therapies may be beneficial for this population, but have not been widely studied.

Purpose:

The purpose of this study was to evaluate potential effects of acupuncture, guided imagery, Healing Touch, massage therapy, and reflexology on pain and anxiety of hospitalized pregnant women.

Methods:

A retrospective analysis of the effects of integrative medicine therapies was conducted; N = 554 individual therapies were provided to hospitalized women with high-risk pregnancies. They included acupuncture (n = 83), guided imagery (n = 71), Healing Touch (n = 119), massage therapy (n = 196), and reflexology (n = 85) over an 18-month period. Pain and anxiety were measured pre- and posttherapy using a scale of 0 to 10, where 0 means no pain or no anxiety and 10 means high pain or high anxiety.

Results:

Analysis of mean scores of pre- and posttherapies for pain and anxiety found a decrease of pain and anxiety after all of the therapies, ranging from an 84.5% to 61.4% decrease for pain (p < .0001) and a 91% to 70. 9% decrease for anxiety (p < .0001). Overall, patients rated their anxiety higher than pain prior to each therapy.

Clinical Implications:

Hospitalized pregnant women responded favorably to the therapies. There were no adverse reactions reported. Results suggest potential benefits of integrative medicine therapies for this group of inpatients. Anxiety was more prevalent than pain among hospitalized pregnant women who received integrative medicine therapy.
Profiles of Depression Help Seeking Among Black Americans
Authors: Hays Krystal , Gilreath Tamika
Published: August 2016

Although Black Americans have lower prevalence of depression compared to non-Hispanic Whites (10% vs. 17%), they are nearly twice as likely to have worse outcomes. One contributor to poor depression outcomes involves the ways in which Black Americans seek help for depression. However, little is known about depression help-seeking behavior, and the use of multiple sources of help, among Black Americans. This study used latent class analysis to identify unique constellations of depression help seeking, from multiple sources, among African American and Black Caribbeans. Results indicated four profiles of depression help seeking including Informal/Primary Care Utilizers (41.4%), Formal Mental Health Utilizers (40.6%), All Support Utilizers (9.8%), and Mixed Source Utilizers (8.2%). The constellation of each profile and demographic differences in class assignment are discussed. Results have implications for tailored depression interventions for Black Americans including community-based psychoeducation and cultural competence training for mental health providers.
Vision Therapy for Post-Concussion Vision Disorders
Authors: Gallaway Michael , Scheiman Mitchell , Mitchell G. Lynn
Published: August 2016

Purpose

To determine the frequency and types of vision disorders associated with concussion, and to determine the success rate of vision therapy for these conditions in two private practice settings.

Methods

All records over an 18-month period of patients referred for post-concussion vision problems were reviewed from two private practices. Diagnoses of vergence, accommodative, or eye movement disorders were based on pre-established, clinical criteria. Vision therapy was recommended based on clinical findings and symptoms.

Results

Two hundred eighteen patient records were found with a diagnosis of concussion. Fifty-six percent of the concussions were related to sports, 20% to automobile accidents, and 24% to school, work, or home-related incidents. The mean age was 20.5 years and 58% were female. Eighty-two percent of the patients had a diagnosis of an oculomotor problem [binocular problems (62%), accommodative problems (54%), eye movement problems (21%)]. The most prevalent diagnoses were convergence insufficiency (CI, 47%) and accommodative insufficiency (AI, 42%). Vision therapy was recommended for 80% of the patients. Forty-six per cent (80/175) either did not pursue treatment or did not complete treatment. Of the 54% (95/175) who completed therapy, 85% of patients with CI were successful and 15% were improved, and with AI, 33% were successful and 67% improved. Clinically and statistically significant changes were measured in symptoms, near point of convergence, positive fusional vergence, and accommodative amplitude.

Conclusions

In this case series, post-concussion vision problems were prevalent and CI and AI were the most common diagnoses. Vision therapy had a successful or improved outcome in the vast majority of cases that completed treatment. Evaluation of patients with a history of concussion should include testing of vergence, accommodative, and eye movement function. Prospective clinical trials are necessary to assess the natural history of concussion-related vision disorders and treatment effectiveness.
Regressive Retinal Flecks in CRX-Mutated Early-Onset Retinal Dystrophy
Authors: Cicinelli Maria Vittoria , Manitto Maria Pia , Parodi Maurizio Battaglia , Bandello Francesco
Published: August 2016

Purpose

To describe a peculiar flecked-retina phenotype in a young female affected by early-onset retinal dystrophy due to a heterozygous mutation in the cone-rod transcription factor CRX gene.

Case Report

A 5-year-old girl presented with poor vision and nystagmus from the first month after birth. Opththalmologic examination at baseline revealed an altered foveal reflex, epiretinal membrane, and yellow fleck-like retinal deposits in the mid- and extreme periphery bilaterally that disappeared after 3 years of follow-up. Electoretinogram was non-recordable in both rods and cones components bilaterally. Genomic sequencing identified a heterozygous missense mutation −c.425A > G (Tyr142Cys) in CRX.

Conclusions

We identified a novel early-onset retinal dystrophy-related heterozygous CRX mutation associated with early and severe rod and cone dysfunction and regressive flecked-retina appearance on ophthalmoscopy.
Visual Acuity and Self-Reported Visual Function among Migrant Farmworkers
Authors: Quandt Sara A. , Schulz Mark R. , Chen Haiying , Arcury Thomas A.
Published: August 2016

Purpose

Visual impairment presents significant risks for occupational injuries among farmworkers, a vulnerable population with limited access to vision care. Although previous research has noted farmworkers’ low lifetime experience with vision screening and high rates of complaints of eye ailments and poor vision, there have been few screening data collected to evaluate these self-reports. The objectives of this analysis are to (1) describe farmworker visual health using standardized visual acuity screening data and self-reported visual function, and (2) to compare the screening and self-report data.

Methods

Data are from a cross-sectional study of eye health among Latino migrant farmworkers in North Carolina with uncorrected vision (n = 289). Workers were recruited using methods to achieve a representative sample of a hard-to-reach population. Visual acuity data were collected using Snellen Tumbling E charts for nearsightedness and farsightedness. Binocular data are reported here. Interviews were conducted to obtain personal characteristics and self-assessed visual function.

Results

About 75% of farmworkers reported never having had a vision screening. Based on binocular screening, 1.7% (distance vision) and 6.9% (near vision) had moderate to severe visual impairment (>20/40). Farmworkers self-reported poorer visual function, compared with screening results; only 36.4% reported good or very good vision. Sensitivity of distance and near vision self-reports were 60 and 20%, respectively, but specificity was high.

Conclusions

This study confirms past reports of little vision screening among farmworkers. Visual impairment for distance is comparable to other studies of Latinos in the US, though these studies have not reported near vision. Self-reports of vision problems are not a sensitive measure of visual acuity among farmworkers. Screening is needed to identify visual impairment that can create occupational safety risks in this health disparate population.
Holographic Refraction and the Measurement of Spherical Ametropia
Authors: Nguyen Nicholas Hoai Nam
Published: August 2016

Purpose

To evaluate the performance of a holographic logMAR chart for the subjective spherical refraction of the human eye.

Methods

Bland-Altman analysis was used to assess the level of agreement between subjective spherical refraction using the holographic logMAR chart and conventional autorefraction and subjective spherical refraction.

Results

The 95% limits of agreement (LoA) were calculated between holographic refraction and the two standard methods (subjective and autorefraction). Holographic refraction has a lower mean spherical refraction when compared to conventional refraction (LoA 0.11 ± 0.65 D) and when compared to autorefraction (LoA 0.36 ± 0.77 D). After correcting for systemic bias, this is comparable between autorefraction and conventional subjective refraction (LoA 0.45 ± 0.79 D). After correcting for differences in vergence distance and chromatic aberration between holographic and conventional refraction, approximately 65% (group 1) of measurements between holography and conventional subjective refraction were similar (MD = 0.13 D, SD = 0.00 D). The remaining 35% (group 2) had a mean difference of 0.45 D (SD = 0.12 D) between the two subjective methods. Descriptive statistics showed group 2’s mean age (21 years, SD = 13 years) was considerably lower than group 1’s mean age (41 years, SD = 17), suggesting accommodation may have a role in the greater mean difference of group 2.

Conclusions

Overall, holographic refraction has good agreement with conventional refraction and is a viable alternative for spherical subjective refraction. A larger bias between holographic and conventional refraction was found in younger subjects than older subjects, suggesting an association between accommodation and myopic over-correction during holographic refraction.
A Fatal Case of a Ruptured Cerebral Aneurysm Detected by Postmortem Computed Tomography Angiography Using a New Contrast-Medium Solution
Authors: Stamou Stamatios , Gascho Dominic , Eggert Sebastian , Berger Florian , Thali Michael J. , Flach Patricia M.
Published: August 2016

Forensic autopsy is still the criterion standard in legal investigations. Currently, notable transformation is occurring because postmortem imaging is being increasingly endorsed. This article highlights the effectiveness of postmortem computed tomography angiography by using a new contrast medium mixture as a solitary tool to define the cause and manner of death in a ruptured cerebral aneurysm case. Based on the imaging results, autopsy was not mandated and the case was closed.
HER2 Status in Gastric and Gastroesophageal Junction Cancer: Results of the Large, Multinational HER-EAGLE Study
Authors: Kim Woo-Ho , Gomez-Izquierdo Lourdes , Vilardell Felip , Chu Kent-Man , Soucy Geneviève , dos Santos Lucas V. , Monges Geneviève , Viale Giuseppe , Brito Maria José , Osborne Stuart , Noé Johannes , Du Xiang
Published: August 2016

Human epidermal growth factor receptor 2 (HER2) dysregulation is associated with tumorigenesis in gastric/gastroesophageal junction cancer; however, the number of patients with HER2-positive disease is unclear, possibly due to differing scoring criteria/assays. Data are also lacking for early disease. We aimed to assess the HER2-positivity rate using approved testing criteria in a large, real-life multinational population. HER2-positivity was defined as an immunohistochemistry staining score of 3+, or immunohistochemistry 2+ and HER2 amplification detected by in situ hybridization. A total of 4949 patients were enrolled and results showed that 14.2% of 4920 samples with immunohistochemistry results were HER2-positive. HER2-positivity was significantly higher in males (16.1% vs. 9.6% in females), in gastroesophageal versus stomach tumors (22.1% vs. 12.9%), in biopsy versus surgical samples (18.3% vs. 13.0%), in intestinal tumor subtypes versus diffuse (21.5% vs. 4.8%) and mixed types (21.5% vs. 8.5%) (P<0.001), in mixed versus diffuse types (8.5% vs. 4.8%), and in “other” versus diffuse types (11.7% vs. 4.8%; P=0.002). There were no significant differences between stages. Patients in the youngest age percentile had significantly lower HER2-positivity rates than patients in the remaining percentiles (9.2% vs. 15.9%, 15.7%, and 15.1%; P<0.001). HER2-positivity was highest in France (20.2%) and lowest in Hong Kong (10.4%). In conclusion, HER-EAGLE, the first study of its kind to be conducted in a large, multinational population of almost 5000 patients, gives valuable insights into the real-world HER2-positivity rate in a gastric/gastroesophageal junction cancer patient population not selected for disease stage or histology.
Undifferentiated Carcinoma With Osteoclastic Giant Cells of the Pancreas
Authors: Muraki Takashi , Reid Michelle D. , Basturk Olca , Jang Kee-Taek , Bedolla Gabriela , Bagci Pelin , Mittal Pardeep , Memis Bahar , Katabi Nora , Bandyopadhyay Sudeshna , Sarmiento Juan M. , Krasinskas Alyssa , Klimstra David S. , Adsay Volkan
Published: August 2016

Undifferentiated carcinomas with osteoclastic giant cells of the pancreas (OGC) are rare tumors. The current impression in the literature is that they are highly aggressive tumors similar in prognosis to ductal adenocarcinomas. In this study, the clinicopathologic characteristics of 38 resected OGCs were investigated and contrasted with 725 resected pancreatic ductal adenocarcinomas without osteoclastic cells (PDCs). The frequency among systematically reviewed pancreatic cancers was 1.4%. OGCs showed a slight female predominance (62.9%, vs. 51.4% in PDCs). The mean age was 57.9 years (vs. 65.0). The mean size of invasive cancer was 5.3 cm (vs. 3.2). They were characterized by nodular, pushing-border growth, and 8 arose in tumoral intraepithelial neoplasms (4 in mucinous cystic neoplasms, 4 in intraductal papillary mucinous neoplasms type lesions), and 23 (61%) also showed prominent intraductal/intracystic growth. Twenty-nine (76%) had an invasive ductal/tubular adenocarcinoma component. Osteoid was seen in 12. Despite their larger size, perineural invasion and nodal metastasis were uncommon (31.6% and 22.6%, vs. 85.5% and 64.0%, respectively). Immunohistochemistry performed on 24 cases revealed that osteoclastic cells expressed the histiocytic marker CD68, and background spindle cells and pleomorphic/giant carcinoma cells often showed p53 and often lacked cytokeratin. Survival of OGCs was significantly better than that of PDCs (5 yr, 59.1% vs. 15.7%, respectively, P=0.0009). In conclusion, pancreatic OGCs present with larger tumor size and in slightly younger patients than PDC, 21% arise in mucinous cystic neoplasms/intraductal papillary mucinous neoplasms, and 61% show intraductal/intracystic polypoid growth. OGCs have a significantly better prognosis than is currently believed in the literature.
Chronic Heart Failure
Authors: Hoffman Timothy M.
Published: August 2016

Objectives:

The objectives of this review are to discuss the paradigms used to stage heart failure in children, the classification and physiologic profile of cardiomyopathies, and the acute and chronic pharmacologic management of heart failure.

Data Source:

MEDLINE, PubMed.

Conclusion:

The etiology of chronic heart failure in pediatrics is vast. The paradigm of extrapolating adult clinical trials and technological advancements to treat heart failure in children has become a nonsustainable model. The field of pediatric heart failure continues to advance with more robust guideline-directed care and the imminent creation of a dynamic, contemporary international database. As the field involves a markedly heterogeneous patient population, it is imperative to use pediatric specific descriptors of disease impact. The fields of pediatric heart failure and critical care medicine will continue to evolve together as childhood specific registries, quality improvement guidelines, and research will lead to practice models eliciting optimal therapy for patients with heart failure in the intensive care setting.
Intensive Care in the Adult With Congenital Heart Disease
Authors: Redington Andrew
Published: August 2016

Objectives:

The purpose of this review is to discuss current outcomes for patients with adult congenital heart disease, assess the level of knowledge regarding the impact of comorbidities, and discuss the various models of care with a view to establish the optimal environment for the care of these patients in the future.

Data Source:

MEDLINE and PubMed.

Conclusion:

There is an increasingly large population of adults with previously operated congenital heart disease. Consequently, there are increasing numbers of adults requiring intensive care support after re-do surgery, or as a consequence of medical complications of their underlying cardiac disease. There is relatively little data specific to this population to guide optimal disposition and care models.
Shunt Lesions Part I: Patent Ductus Arteriosus, Atrial Septal Defect, Ventricular Septal Defect, and Atrioventricular Septal Defect
Authors: Backer Carl L. , Eltayeb Osama , Mongé Michael C. , Mazwi Mjaye L. , Costello John M.
Published: August 2016

Objectives:

This review summarizes the current understanding of the pathophysiology and perioperative management of patent ductus arteriosus, atrial septal defect, ventricular septal defect, and atrioventricular septal defect.

Data Source:

MEDLINE and PubMed.

Conclusions:

The four congenital cardiac lesions that are the subject of this review, patent ductus arteriosus, atrial septal defect, ventricular septal defect, and atrioventricular septal defect, are the most commonly found defects causing a left-to-right shunt. These defects frequently warrant transcatheter or surgical intervention. Although the perioperative care is relatively straightforward for many of these patients, there are a number of management strategies and complications associated with each intervention. The treatment outcomes for all of these lesions are very good in the current era.
Right Ventricular Outflow Tract Obstruction: Pulmonary Atresia With Intact Ventricular Septum, Pulmonary Stenosis, and Ebstein’s Malformation
Authors: Kwiatkowski David M. , Hanley Frank L. , Krawczeski Catherine D.
Published: August 2016

Objectives:

The objectives of this review are to discuss the anatomy, pathophysiology, clinical course, and current treatment strategies for pulmonary atresia with intact ventricular septum, pulmonary stenosis, and Ebstein’s anomaly.

Data Source:

MEDLINE and PubMed.

Conclusions:

Considerable advances have been made in management strategies for these complex congenital heart lesions, which have led to improved outcomes.
Comorbid Conditions in Neonates With Congenital Heart Disease
Authors: Krishnamurthy Ganga , Ratner Veniamin , Bacha Emile , Aspelund Gudrun
Published: August 2016

Objectives:

The objectives of this review are to discuss the pathophysiology, clinical impact and treatment of major noncardiac anomalies, and prematurity in infants with congenital heart disease.

Data Source:

MEDLINE and PubMed.

Conclusion:

Mortality risk is significantly higher in patients with congenital heart disease and associated anomalies compared with those in whom the heart defect occurs in isolation. Although most noncardiac structural anomalies do not require surgery in the neonatal period, several require surgery for survival. Management of such infants poses multiple challenges. Premature infants with congenital heart disease face challenges imposed by their immature organ systems, which are susceptible to injury or altered function by congenital heart disease and abnormal circulatory physiology independent of congenital heart disease. For optimal outcomes in premature infants or in infants with multiple congenital anomalies, a collaborative interdisciplinary approach is necessary.
Multisite Tissue Oxygenation Monitoring Indicates Organ-Specific Flow Distribution and Oxygen Delivery Related to Low Cardiac Output in Preterm Infants With Clinical Sepsis
Authors: van der Laan Michelle E. , Roofthooft Marcus T. R. , Fries Marian W. A. , Schat Trijntje E. , Bos Arend F. , Berger Rolf M. F. , Kooi Elisabeth M. W.
Published: August 2016

Objectives:

Cardiac output may be compromised in preterm infants with sepsis. Whether low cardiac output is associated with low tissue oxygen supply in these patients is unclear. The aim of the current study was to assess the association between cardiac output, assessed by echocardiography, and tissue oxygenation, measured with multisite near-infrared spectroscopy, in a cohort of preterm infants with clinical sepsis.

Design:

Prospective observational cohort study.

Setting:

Level III neonatal ICU.

Patients:

Twenty-four preterm infants (gestational age < 32 wk) with clinical sepsis.

Interventions:

None.

Measurements and Main Results:

Clinical and echocardiographic assessment of hemodynamics was performed within 48 hours of sepsis workup and repeated at least 24 hours later. We measured cerebral, renal, and intestinal tissue oxygen saturation using near-infrared spectroscopy during an hour of stable measurements directly preceding or following echocardiography and calculated fractional tissue oxygen extraction in each tissue. We determined Spearman correlation coefficients between fractional tissue oxygen extraction and right ventricular output corrected for patent foramen ovale flow, left ventricular output corrected for ductus arteriosus flow, and superior vena cava flow. Right ventricular output corrected for patent foramen ovale and left ventricular output corrected for ductus arteriosus flow both correlated significantly with intestinal fractional tissue oxygen extraction (ρ, –0.700; p = 0.036 and ρ, –0.604; p = 0.029, respectively). In contrast, no significant correlations were found between cardiac output measurements and cerebral and renal fractional tissue oxygen extraction, respectively. Changes in cardiac output measurements were not associated with observed changes in fractional tissue oxygen extraction values.

Conclusions:

Right ventricular output corrected for patent foramen ovale and left ventricular output corrected for ductus arteriosus flow, indicators of systemic blood flow in preterm infants with shunts, were negatively associated with intestinal fractional tissue oxygen extraction, but not with renal and cerebral fractional tissue oxygen extraction. These findings suggest that during low output states due to clinical sepsis intestinal perfusion is most at risk.
The Current State of the Diagnosis and Management of Acute Kidney Injury by Pediatric Critical Care Physicians*
Authors: Hassinger Amanda B. , Garimella Sudha , Wrotniak Brian H. , Freudenheim Jo L.
Published: August 2016

Objectives:

Increasingly prevalent in pediatric intensive care, acute kidney injury imparts significant short- and long-term consequences. Despite advances in acute kidney injury research, clinical outcomes are worsening. We surveyed pediatric critical care physicians to describe the current state of acute kidney injury diagnosis and management in critically ill children.

Design:

Anonymous electronic questionnaire.

Participants:

Pediatric critical care physicians from academic centers, the Pediatric Acute Lung Injury and Sepsis Investigators network, and/or the pediatric branch of Society of Critical Care Medicine.

Interventions:

None.

Measurements and Main Results:

Of 201 surveys initiated, 170 surveys were more than 50% completed and included in our results. The majority of physicians (74%) diagnosed acute kidney injury using serum creatinine and urine output. Acute kidney injury guidelines or criteria were used routinely by 54% of physicians; Risk, Injury, Failure, Loss, and End stage criteria were the most commonly used. Awareness of any acute kidney injury guideline or definition was associated with five-fold higher odds of using any guideline (odds ratio, 5.22; 95% CI, 1.84–14.83) and four-fold higher odds of being dissatisfied with available acute kidney injury biomarkers (odds ratio, 4.88; 95% CI, 1.58–15.05). Less than half of respondents recognized the limitations of serum creatinine. Physicians unaware of the limitations of serum creatinine had two-fold higher odds of being unaware of newer biomarker availability (odds ratio, 2.34; 95% CI, 1.14–4.79). Novel biomarkers were available to 37.6% of physicians for routine use. Physicians with access to novel biomarkers more often practiced in larger (odds ratio, 3.09; 95% CI, 1.18–8.12) and Midwestern (odds ratio, 3.38; 95% CI, 1.47–7.78) institutions. More physicians with access to a novel biomarker reported satisfaction with current acute kidney injury diagnostics (66%) than physicians without access (48%); this finding approached significance (p = 0.07).

Conclusions:

Half of PICU attending physicians surveyed are not using recent acute kidney injury guidelines or diagnostic criteria in their practice. There is a positive association between awareness and clinical use of acute kidney injury guidelines. Serum creatinine and urine output are still the primary diagnostics; novel biomarkers are frequently unavailable.
Inotropic Therapy in Newborns, A Population-Based National Registry Study*
Authors: Burns Margrete Larsen , Stensvold Hans Jørgen , Risnes Kari , Guthe Hans Jørgen , Astrup Henriette , Nordhov S. Marianne , Selberg Terje Reidar , Rønnestad Arild , Lang Astri Maria
Published: August 2016

Objective:

To describe the use of inotropic drugs and the characteristics of neonates receiving such treatment in a national cohort of patients admitted to neonatal ICUs in Norway.

Design:

A national registry study of patients included in the Norwegian Neonatal Network database 2009–2014. Demographic and treatment data, including the use of inotropic drugs (dopamine, dobutamine, epinephrine, norepinephrine, milrinone, and levosimendan) and outcomes, were retrieved and analyzed.

Setting:

Neonatal ICUs in Norway.

Patients:

All patients admitted to Norwegian neonatal ICUs 2009–2014 with a postmenstrual age of less than 310 days at admission, corresponding to a postnatal age of less than 28 days for a child born at term (n = 36 397).

Interventions:

None.

Measurements and Main Results:

Inotropic drugs were administered to 974 of 361,803 live born infants (0.27%) in the study period, representing 2.7% of the neonatal ICU patient population. The relative proportion of neonatal ICU patients receiving inotropes decreased with increasing gestational age, yet 41% of the patients receiving inotropes were born at term. Of note, 89.8% of treated patients received dopamine. Use of inotropes was particularly prevalent in patients with necrotizing enterocolitis (72.4%) and pulmonary hypertension (42.1%) and in patients with gestational age less than 28 weeks (28.2%). Inotropic treatment initiated in the first week of life (84.2%) was associated with birth asphyxia and pulmonary hypertension, whereas treatment initiated after the first week of life was associated with extremely preterm birth, neonatal surgery, neonatal sepsis, cardiac disease, and necrotizing enterocolitis.

Conclusions:

This comprehensive epidemiologic study indicates that less than 0.3% of newborns receive inotropic support in the neonatal period. Dopamine was the most commonly used drug. Relating inotrope use to clinical condition, gestational age, and postnatal age may be useful for clinicians and helpful in delineating relevant patient populations for future clinical trials.
Poor Adherence to Lung-Protective Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome*
Authors: Ward Shan L. , Quinn Carson M. , Valentine Stacey L. , Sapru Anil , Curley Martha A. Q. , Willson Douglas F. , Liu Kathleen D. , Matthay Michael A. , Flori Heidi R.
Published: August 2016

Objectives:

To determine the frequency of low-tidal volume ventilation in pediatric acute respiratory distress syndrome and assess if any demographic or clinical factors improve low-tidal volume ventilation adherence.

Design:

Descriptive post hoc analysis of four multicenter pediatric acute respiratory distress syndrome studies.

Setting:

Twenty-six academic PICU.

Patients:

Three hundred fifteen pediatric acute respiratory distress syndrome patients.

Measurements and Main Results:

All patients who received conventional mechanical ventilation at hours 0 and 24 of pediatric acute respiratory distress syndrome who had data to calculate ideal body weight were included. Two cutoff points for low-tidal volume ventilation were assessed: less than or equal to 6.5 mL/kg of ideal body weight and less than or equal to 8 mL/kg of ideal body weight. Of 555 patients, we excluded 240 for other respiratory support modes or missing data. The remaining 315 patients had a median Pao
2-to-Fio
2 ratio of 140 (interquartile range, 90–201), and there were no differences in demographics between those who did and did not receive low-tidal volume ventilation. With tidal volume cutoff of less than or equal to 6.5 mL/kg of ideal body weight, the adherence rate was 32% at hour 0 and 33% at hour 24. A low-tidal volume ventilation cutoff of tidal volume less than or equal to 8 mL/kg of ideal body weight resulted in an adherence rate of 58% at hour 0 and 60% at hour 24. Low-tidal volume ventilation use was no different by severity of pediatric acute respiratory distress syndrome nor did adherence improve over time. At hour 0, overweight children were less likely to receive low-tidal volume ventilation less than or equal to 6.5 mL/kg ideal body weight (11% overweight vs 38% nonoverweight; p = 0.02); no difference was noted by hour 24. Furthermore, in the overweight group, using admission weight instead of ideal body weight resulted in misclassification of up to 14% of patients as receiving low-tidal volume ventilation when they actually were not.

Conclusions:

Low-tidal volume ventilation is underused in the first 24 hours of pediatric acute respiratory distress syndrome. Age, Pediatric Risk of Mortality-III, and pediatric acute respiratory distress syndrome severity were not associated with improved low-tidal volume ventilation adherence nor did adherence improve over time. Overweight children were less likely to receive low-tidal volume ventilation strategies in the first day of illness.
Frequency, Composition, and Predictors of In-Transit Critical Events During Pediatric Critical Care Transport*
Authors: Singh Jeffrey M. , Gunz Anna C. , Dhanani Sonny , Aghari Mahvareh , MacDonald Russell D.
Published: August 2016

Objectives:

Transport of pediatric patients is common due to healthcare regionalization. We set out to determine the frequency of in-transit critical events during pediatric critical care transport and identify factors associated with these events.

Design:

Retrospective cohort study using administrative and clinical data.

Setting:

Single pediatric critical care transport provider in Ontario, Canada.

Patients:

All pediatric care transports between January 1, 2005, and December 31, 2010.

Measurements and Main Results:

The primary outcome was in-transit critical events, defined by an adaptation of a recent consensus definition. In-transit critical events occurred in 1,094 (12.3%) of 8,889 transports. Hypotension (3.6%), tachycardia (3.7%), and bradycardia (3.3%) were the most common critical events. Crews performed medical interventions in 194 transports (2.2%). The frequency and makeup of critical events varied across patient age groups. Age, pretransport mechanical ventilation, pretransport cardiovascular instability, transport duration, scene calls, and paramedic crew level were independently associated with increased risk of in-transit critical events in multivariate analysis. A Transport Pediatric Early Warning Score of 7 or greater predicted in-transit critical events with high specificity but low sensitivity (92.0% and 20.0%, respectively), but was not superior of the combination of pretransport mechanical ventilation and pretransport cardiovascular instability (sensitivity and specificity of 12.6% and 97.4%, respectively). Removal of early warning signs from the definition resulted in critical event rates comparable to those published in adults and improved predictive performance.

Conclusions:

Using new consensus definitions of transport-related critical events, we found critical events occurred in almost one in eight transports, and were strongly associated with pretransport cardiovascular instability. Transport Pediatric Early Warning Score was poorly predictive of in-transit critical events, and was not superior to the presence of pretransport mechanical ventilation and cardiovascular instability. Future prospective studies are required to elucidate the optimal matching of transport resources to patients, in particular those with both pretransport cardiovascular instability and mechanical ventilation.
Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium*
Authors: Grunwell Jocelyn R. , Travers Curtis , McCracken Courtney E. , Scherrer Patricia D. , Stormorken Anne G. , Chumpitazi Corrie E. , Roback Mark G. , Stockwell Jana A. , Kamat Pradip P.
Published: August 2016

Objective:

Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events.

Design:

Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium.

Setting:

Sedation services from academic, community, free-standing children’s hospitals and pediatric wards within general hospitals.

Patients:

Children from birth to 21 years old or younger.

Interventions:

None.

Measurements and Main Results:

Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92–7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60–1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm.

Conclusions:

This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.
Evaluation of Anaphylaxis Management in a Pediatric Emergency Department
Authors: Sidhu Natasha , Jones Stacie , Perry Tamara , Thompson Tonya , Storm Elizabeth , Melguizo Castro Maria S. , Nick Todd G.
Published: August 2016

Objective

In 2006, the National Institute of Allergy and Infectious Disease established evidence-based treatment guidelines for anaphylaxis. The purpose of our study was to evaluate provider adherence to guidelines-based management for anaphylaxis in a tertiary care pediatric emergency department (ED).

Methods

Retrospective chart review was conducted of patients (0–18 years) presenting to the Arkansas Children Hospital ED from 2004 to 2011 for the treatment of anaphylaxis using International Classification of Diseases, Ninth Edition, codes. Multiple characteristics including demographics, clinical features, allergen source, and anaphylaxis management were collected. Fisher exact or χ2 tests were used to compare proportion of patients treated with intramuscular (IM) epinephrine in the preguideline versus postguideline period. Relative risk (RR) statistics were computed to estimate the ratio of patients who received self-injectable epinephrine prescription and allergy follow-up in the preguideline and postguideline groups.

Results

A total of 187 patients (median [range] age, 7 [1–18] years; 67% male; 48% African American) were evaluated. Food (44%) and hymenoptera stings (22%) were commonly described culprit allergens, whereas 29% had no identifiable allergen. Only 47% (n = 87) received epinephrine in the ED and 31% (n = 27) via the preferred IM route. Comparing postguideline (n = 126) versus preguideline (n = 61) periods demonstrated increase in the usage of the IM route (46% postguideline vs 6% preguideline; risk ratio (RR), 7.64; 95% confidence interval [CI], 2.04–46.0; P < 0.001). Overall, 61% (n = 115) of the patients received self-injectable epinephrine upon discharge, and there were no significant differences between the groups (64% postguideline vs 56% preguideline, P = 0.30). Postguideline patients were more likely to receive a prescription compared with preguideline patients (64% postguideline vs 56% preguideline; RR, 1.15; 95% CI, 0.89–1.55; P = 0.30). Only 45% (n = 85) received an allergy referral. Postguideline patients were more likely to receive an allergy referral than preguideline patients (48% postguideline vs 41% preguideline; RR, 1.16; 95% CI, 0.81–1.73; P = 0.40).

Conclusions

Provider use of IM epinephrine has improved since anaphylaxis guidelines were published. However, more provider education is needed to improve overall adherence of guidelines in a tertiary care pediatric ED.