bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of ACA Insurance Coverage Expansion on Perforated Appendix Rates Among Young Adults
Authors: Scott John W. , Rose John A. , Tsai Thomas C. , Zogg Cheryl K. , Shrime Mark G. , Sommers Benjamin D. , Salim Ali , Haider Adil H.
Published: July 2016

Background:

The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act allowed young adults to remain on their parents’ health insurance plans until age 26 years. Although the provision improved coverage and survey-reported access to care, little is known regarding its impact on timely access for acute conditions. This study aims to assess changes in insurance coverage and perforation rates among young adults with acute appendicitis—an established metric for population-level health care access—after the DCP.

Methods:

The National Inpatient Sample and difference-in-differences linear regression were used to assess prepolicy/postpolicy changes for policy-eligible young adults (aged 19–25 y) compared with a slightly older, policy-ineligible comparator group (aged 26–34 y).

Results:

After adjustment for covariates, 19–25 year olds experienced a 3.6-percentage point decline in the uninsured rate after the DCP (baseline 22.5%), compared with 26–34 year olds (P<0.001). This coincided with a 1.4-percentage point relative decline in perforated appendix rate for 19–25 year olds (baseline 17.5%), compared with 26–34 year olds (P=0.023). All subgroups showed significant reductions in uninsured rates; however, statistically significant reductions in perforation rates were limited to racial/ethnic minorities, patients from lower-income communities, and patients presenting to urban teaching hospitals.

Conclusions:

Reductions in uninsured rates among young adults after the DCP were associated with significant reductions in perforated appendix rates relative to a comparator group, suggesting that insurance expansion could lead to fewer delays in seeking and accessing care for acute conditions. Greater relative declines in perforation rates among the most at-risk subpopulations hold important implications for the use of coverage expansion to mitigate existing disparities in access to care.
Comorbidity Correlates of Death Among New Veterans of Iraq and Afghanistan Deployment
Authors: Copeland Laurel A. , Finley Erin P. , Bollinger Mary J. , Amuan Megan E. , Pugh Mary Jo V.
Published: July 2016

Background:

Veterans of the wars in Iraq and Afghanistan who receive care in the Veterans Health Administration (VA) have high disease burden. Distinct comorbidity patterns have been shown to be differentially associated with adverse outcomes, including death. This study determined correlates of 5-year mortality.

Materials and Methods:

VA demographic, military, homelessness, and clinical measures informed this retrospective analysis. Previously constructed comorbidity classifications over 3 years of care were entered into a Cox proportional hazards model of death.

Results:

There were 164,933 veterans in the cohort, including African Americans (16%), Hispanics (11%), and whites (65%). Most were in their 20s at baseline (60%); 12% were women; 4% had attempted suicide; 4% had been homeless. Having clustered disorders of pain, posttraumatic stress disorder, and traumatic brain injury was associated with death [hazard ratio (HR)=2.0]. Mental disorders including substance abuse were similarly associated (HR=2.1). Prior suicide attempt (HR=2.2) or drug overdose (HR=3.0) considerably increased risk of death over 5 years.

Conclusions:

As congressional actions such as Veterans Choice Act offer more avenues to seek care outside of VA, coordination of care, and suicide prevention outreach for recent veterans may require innovative approaches to preserve life.
Antithrombotic potential of the contact activation pathway
Authors: Schmaier Alvin H.
Published: July 2016

Purpose of review

This report examines the mechanism(s) by which each protein of the contact activation system – factor XII (FXII), high-molecular-weight kininogen, and prekallikrein – influences thrombosis risk.

Recent findings

FXII generates thrombin through contact activation via interaction with artificial surfaces as on medical instruments such as indwelling catheters, mechanical valves, stents, and ventricular assist devices. Inhibition of FXIIa-mediated contact activation prevents thrombosis under contact activation circumstances without affecting hemostasis. Current studies suggest that high-molecular-weight kininogen deficiency parallels that of FXII and inhibits contact activation. Prekallikrein inhibition contributes to thrombosis prevention by contact activation inhibition in the nylon monofilament model of transient middle cerebral artery occlusion. However, in arterial thrombosis models where reactive oxygen species are generated, prekallikrein deficiency results in downregulation of vessel wall tissue factor generation with reduced thrombin generation. Exploiting this latter prekallikrein pathway for thrombosis risk reduction provides a general, overall reduced tissue factor, antithrombotic pathway without risk for bleeding.

These investigations indicate that the proteins of the contact activation and kallikrein/kinin systems influence thrombosis risk by several mechanisms and understanding of these pathway provides insight into several novel targets to prevent thrombosis without increase in bleeding risk.
Management and reconstruction of blast wounds of the head and neck
Authors: Stevens Jayne R. , Brennan Joseph
Published: July 2016

Purpose of review

The purpose of this review is to highlight recent literature related to the initial management and reconstruction of blast injuries to the head and neck.

Recent findings

An increasing percentage of combat-related injuries are caused by blast trauma. Management of blast trauma over the last 10 years has improved understanding of the unique nature of these injuries and the importance of thoughtful management and reconstruction. Blast trauma is associated with an increased need for definitive airway management. As a result, initial triage principles of airway management and hemorrhage control are extremely important in the acute setting. Blast trauma results in high-velocity injuries that can lead to extensive soft tissue damage, which has important implications for reconstruction. Staging reconstruction is an important consideration for more extensive injuries.

Experience on the battlefield with blast injuries over the last decade has led to efficient triage with focus on hemorrhage and airway control. The lessons learned in Iraq and Afghanistan with the unique physiology of blast trauma have improved the casualty care of service members and can be used both in future military conflicts and in civilian trauma care.
Current state of stem cell-mediated therapies for facial nerve injury
Authors: Wang Tiffany V. , Delaney Sean , Pepper Jon-Paul
Published: July 2016

Purpose of review

Interest in the application of stem cell therapy to nerve injury has grown exponentially in recent years, as the armamentarium of potential stem cell sources has increased. This article reviews literature on the recent developments in the application of stem cell therapy for facial nerve injury.

Recent findings

Current stem cell therapy for the treatment of peripheral nerve injury can be generalized into those that either enhance native neural regeneration via an anti-inflammatory effect or growth factor secretion, replace Schwann cells, or replace motor neurons. Animal studies have shown that nerve conduits seeded with stem cells (either undifferentiated or differentiated into Schwann-like cells) in sciatic and facial nerve injury models can promote nerve regeneration with similar efficacy to autologous nerve autografts. In-vivo studies have also shown that induced pluripotent stem cell-derived motor neurons, when transplanted into transected mouse tibial nerves, can form functional neuromuscular junctions with the denervated mouse triceps surae.

The authors believe that induced pluripotent stem cells have significant therapeutic potential. This source of human stem cells can be harvested with little morbidity, is isogenic to the donor, and has fewer ethical concerns compared with embryonic cellular sources. Further research is required to determine stem cell efficacy and safety. Questions of stem cell fate unpredictability and possible tumorigenesis must be addressed prior to human trials.
Double Lumen Polyamide Tube‐stent for the Treatment of Recurrent Postcorrosive Esophageal Stenosis
Authors: Woynarowski Marek , Dądalski Maciej , Wojno Violetta , Teisseyre Mikołaj , Hurkała Leszek , Płowiecki Emil
Published: July 2016

This article presents the results of endoscopic treatment for recurrent postcorrosive esophageal stenosis with a tube‐stent developed at our institution. The tube‐stent was implanted in 5 children with corrosive esophageal injury at the age of 2 to 8.5 years after 7 to 64 dilatation sessions during 5 to 118 months. In total, 13 tube‐stents were implanted. One patient had undergone 9 procedures during 2.5 years and the tube‐stent remained in place for 14 to 250 days. This patient was tube‐stent–dependent due to the lack of any possibility of surgical reconstruction. Two patients had the tube‐stent removed after 150 to 205 days and they remain free from esophageal restenosis. One patient did not tolerate the tube‐stent, evacuated it after 1 day and was referred for surgical esophagus replacement. One patient is currently still being treated with the tube‐stent. Tube‐stent was well tolerated and it may be effective in children with recurrent critical postcorrosive esophageal stenosis.
Outcome of Nephroblastoma Treatment According to the SIOP-2001 Strategy at a Single Institution in Argentina
Authors: Cafferata Constanza , Cacciavillano Walter , Galluzzo María L. , Flores Paula , Rose Adriana , Zubizarreta Pedro
Published: July 2016

Objective:

Wilms tumor (WT) is a disease with a good prognosis. The aim of this study was to evaluate the outcome of patients with WT, treated according to the SIOP-2001 strategy.

Methods:

A retrospective analysis of 141 consecutive patients with WT diagnosed at our institution between December 2001 and 2013 was performed.

Results:

A total of 114 patients, median age 38.8 months (3 to 155 mo), were assessable for analysis. Fine-needle aspiration was initially performed in 88 patients (84.6%). Stage distribution was: I: 33%, II: 9.6%, III: 28%, IV: 14%, V: 14.9%. Six patients were stage III because of tumor spillage. The remaining patients received preoperative chemotherapy. Adjuvant chemotherapy was given without randomization, using vincristine-actinomycin for stage II and vincristine-doxorubicin-actinomycin plus radiotherapy for stage III. After a median follow-up of 52 months, 5-year overall survival and event-free survival were 91% and 85%, respectively. Overall survival according to stage was: I: 96%, II: 99%, III: 88%, IV: 78%, V: 90% (P=0.16). There was no significant difference in event-free survival (P=0.7). Seventy-eight (85.7%) were intermediate-risk and 11 (12%) were high-risk patients. Seventeen patients (14.9%) relapsed within 2 to 99 months (median 29.9 mo). Eight patients (7%) died of progressive disease. There were no treatment-related deaths.

Conclusions:

The SIOP-01 protocol proposes a treatment strategy that is feasible in our institution, achieving good results.
A longitudinal ICF-CY-based evaluation of functioning and disability of children born with very low birth weight
Authors: Fontana Camilla , Picciolini Odoardo , Fumagalli Monica , Mosca Fabio , Bernardelli Giuseppina , Leonardi Matilde , Meucci Paolo , Raggi Alberto , Giovannetti Ambra M.
Published: July 2016

This paper aims to describe the longitudinal changes in disability, defined by the International Classification of Functioning, Disability, and Health – Children and Youth version (ICF-CY) biopsychosocial model, and developmental outcomes in a cohort of 56 very low birth weight children over 14–20 months. We used a neurofunctional assessment, the Griffiths Mental Development Scales-Revised: 2–8 years (Griffiths 2–8) to evaluate psychomotor development and the ICF-CY questionnaire for ages 0–3 and 3–6 to address children’s disability. Extension indexes on the basis of ICF-CY categories were computed, and longitudinal change was tested. Complete follow-up was available for 55 children (mean age 36.7 months, SD 6.7). Considering the sample as a whole, neurofunctional assessment, Griffiths score and disability were basically stable. When the subsample of children with the higher baseline functioning was taken into account, some degree of worsening, in terms of an increase in the number of impairments and limitations, was found. Our results show that disability profiles, neurofunctional assessment and global development were basically stable, except for the subgroup of children who were in the intermediate/high-functioning cluster at baseline. The increased disability among these children might be because of the possibility to observe a wider set of age-specific problems, such as emotional, regulation and social abilities that are not detectable at an early stage of development and that might lead to reduced participation in social activities.
Taking Another View
Authors: Perrigino Matthew B. , Dunford Benjamin B. , Berndt Dawn , Gaston Cynthia L.
Published: July 2016

Based on an organization theory perspective, this study proposes that nurses not only consider how infusion pumps place demands on themselves but also consider how infusion pumps place demands on patients. Results from a sample of nurses in a large, public authority, nonprofit teaching hospital located in the midwestern United States indicate that “demanding formalization for nurses” and “demanding formalization for patients” are 2 empirically distinct constructs. Demanding formalization for patients was a stronger predictor of infusion pump-related attitudes, in addition to trust and pay satisfaction. Demanding formalization for nurses was a stronger predictor of job satisfaction, turnover intention, and burnout.
Medication Errors Involving the Intravenous Administration Route
Authors: Wolf Zane Robinson
Published: July 2016

Characteristics of medication errors involving the intravenous (IV) route of administration were analyzed in reports from 1995 to 2013. This was accomplished through a voluntary medication error reporting program. A retrospective case study design analyzed reports by practitioners or consumers on IV-associated medication errors (N = 975) affecting patients. Patterns in error accounts reflected cultural changes in health care organizations. Equipment, labeling, incorrect route of administration, types of errors, patient outcomes, and causal agents represented major codes. Results point to health care provider and consumer knowledge, the need for ongoing education of nursing staff, and interdisciplinary strategies for preventing IV-associated medication errors.
Decreasing Falls With Injury Rates
Authors: Reich Jessie , Farrell Kathryn , Maloney Courtney , Drayton Deborah , Johnson Tonya
Published: July 2016

Falls with injury are a persistent patient safety challenge in the acute care setting. This article describes the creation and implementation of a Certified Falls Prevention Advocate (CFPA) program on a medical-surgical unit. The program created standardization of nursing support staff involvement in falls prevention and engaged them as members of the interdisciplinary team. The CFPA program was an important element in the unit's improvement in falls with injury rates. The mean falls with injury rate decreased from 1.115 to 0.178 per 1000 patient-days over a 1-year period.
Prevalence and Characteristics of Body Dysmorphic Disorder Among Patients in a Partial Hospital Program
Authors: Bjornsson Andri , Magnusdottir Soffia , Wessman Inga , Beard Courtney , Lee Josephine , Hearon Bridget A. , Björgvinsson Thröstur
Published: July 2016

Body dysmorphic disorder (BDD) is a common disorder that is usually associated with impaired functioning and high levels of suicidality. The current study is the first to assess prevalence of BDD among patients in a partial hospital program and compare patients with and without BDD on demographic and clinical variables. Participants were 207 patients with a variety of Axis I diagnoses. Prevalence of current BDD was 7.2%, and a diagnosis of BDD did not predict worse treatment outcome in the program. Patients with current BDD were more likely to be female and younger and have more comorbid diagnoses than patients without current BDD. No other significant differences were found at baseline between patients with and without current BDD. Results indicate that BDD is relatively common among patients in partial hospital programs and that such programs may be as beneficial to patients with BDD as to other patients.
Parental Divorce or Death During Childhood and Adolescence and Its Association With Mental Health
Authors: Tebeka Sarah , Hoertel Nicolas , Dubertret Caroline , Le Strat Yann
Published: July 2016

Despite the severity of the loss of a parent and the frequency of parental divorce, few studies compared their impact on mental health in the general adult population. The aim of this study was to estimate the prevalence, sociodemographic correlates, and psychiatric comorbidity of parental loss and parental divorce during childhood and adolescence. Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US adults (n = 43,093). Of the 43,093 participants, parental divorce during childhood or adolescence was reported by 5776 participants, whereas 3377 experienced parental death during childhood or adolescence. Participants reporting a history of parental divorce present a significantly higher prevalence of psychiatric disorders, particularly alcohol and drug use disorders compared with control subjects. While participants experiencing the death of a parent reported a poorer overall health, the prevalence of psychiatric disorder after 17 years of age was not significantly higher than that of the control subjects.
Cluster B Personality Disorder Traits as a Predictor of Therapeutic Alliance Over Time in Residential Treatment for Substance Use Disorders
Authors: Olesek Kyle L. , Outcalt Jared , Dimaggio Giancarlo , Popolo Raffaele , George Sunita , Lysaker Paul H.
Published: July 2016

While poor therapeutic alliance is a robust predictor of poor outcome in substance abuse treatment, less is known about the barriers to therapeutic alliances in this group. To explore this issue, this study examined whether the severity of cluster B personality disorders predicted therapeutic alliances concurrently and prospectively in a residential substance treatment program for homeless veterans. Participants were 48 adults with a substance abuse disorder. Personality disorder traits were assessed using the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorders, whereas therapeutic alliance was assessed at baseline using the Working Alliance Inventory. Partial correlations controlling for overall symptom severity measured with the Symptom Checklist 90 and education, revealed cluster B traits at baseline predicted all 4 assessments of therapeutic alliance even after controlling for initial levels of therapeutic alliance. Results suggest that higher levels of cluster B traits are a barrier to the formation of working alliances in residential substance treatment.
Perceived Risk Among Human Immunodeficiency Virus Serodiscordant Couples in East Africa Taking Oral Pre-Exposure Prophylaxis
Authors: Carroll Jennifer J. , Heffron Renee , Mugo Nelly , Ngure Kenneth , Ndase Patrick , Asiimwe Stephen , Celum Connie , Baeten Jared M.
Published: July 2016

Objectives

Perceived risk of human immunodeficiency virus (HIV) infection is thought to drive low adherence in pre-exposure prophylaxis (PrEP) trials. We explored the level of perceived risk of incident HIV infection in the Partners PrEP Study, in which adherence was generally high.

Methods

A cross-sectional questionnaire assessed perceived risk of HIV at 12 months after enrollment. Logistic regression was used to analyze the relationship between perceived risk and other demographic and behavioral variables.

Results

Three thousand two hundred twenty-six couples from the Partners PrEP Study were included in this analysis. Only 15.4% of participants reported high or moderate perceived risk. Participants at high risk of acquiring HIV were slightly more likely to report high perceived risk (odds ratio, 1.60; 95% confidence interval, 1.30–1.95; P < 0.001); nevertheless, only 20% of participants with high-risk reported high perceived risk.

Conclusions

Participants reported low perceived risk of HIV but were adherent to PrEP. Perceptions of risk are likely socially determined and more complex than Likert scale questionnaires capture.
Anal Dysplasia Screening and Treatment in a Southern Human Immunodeficiency Virus Clinic
Authors: Willeford Wesley G. , Barroso Luis , Keller Jennifer , Fino Nora , Bachmann Laura H.
Published: July 2016

Background

Persistent human papillomavirus infection in human immunodeficiency virus (HIV)-infected individuals has been strongly associated with anal squamous cell carcinoma. The incidence of anal squamous cell carcinoma continues to increase in this population despite advances in HIV therapy. There are few studies describing the prevalence of anal cancer precursors, treatment outcomes, and associated factors among HIV-infected populations in the southern United States.

Methods

A retrospective chart review was performed on 355 HIV-infected patients from a Southern HIV clinic who were 18 years or older and had received at least one anal Pap smear. Demographic and clinical variables were collected. Descriptive statistics, single variable, and multivariate logistic regression analysis were performed to evaluate for predictors of high-grade squamous intraepithelial lesion (HSIL). Odds ratios and 95% confidence intervals were constructed for independent measures.

Results

After the first anal Pap smear, 38.3% (70/183) of patients with abnormal results were lost to follow-up. Comparing patients with biopsy proven HSIL versus low-grade squamous intraepithelial lesions, patients were less likely to have HSIL if they had a higher CD4 count (odds ratio, 0.81; 95% confidence interval, 0.72–0.93; P = 0.0022). Treatment success after the first round of treatment for topical and infrared coagulation therapy was 36.7% (18/49, all therapy types), and of those who achieved biopsy proven treatment success at follow-up screening, 94.4% (17/18) required subsequent therapy.

Conclusions

Patients with a higher CD4 count were less likely to have HSIL. CD4 nadir, number of sexual partners, and race/ethnicity were not significantly associated with the presence of HSIL.
Molecular Typing of Treponema pallidum in Ocular Syphilis
Authors: Oliver Sara , Sahi Sharon K. , Tantalo Lauren C. , Godornes Charmie , Neblett Fanfair Robyn , Markowitz Lauri E. , Lukehart Sheila A. , Marra Christina M.
Published: July 2016

Background

Syphilis can have many clinical manifestations, including eye involvement, or “ocular syphilis.” In 2015, an increase in reported cases of ocular syphilis and potential case clusters raised concern for an oculotropic strain of Treponema pallidum, the infectious agent of syphilis. Molecular typing was used to examine strains found in cases of ocular syphilis in the United States.

Methods

In 2015, after a clinical advisory issued by the Centers for Disease Control and Prevention, pretreatment clinical specimens from US patients with ocular syphilis were sent to a research laboratory for molecular analysis of T. pallidum DNA. Molecular typing was conducted on these specimens, and results were compared with samples collected from Seattle patients diagnosed with syphilis, but without ocular symptoms.

Results

Samples were typed from 18 patients with ocular syphilis and from 45 patients with syphilis, but without ocular symptoms. Clinical data were available for 14 ocular syphilis patients: most were men, human immunodeficiency virus–infected, and had early syphilis. At least 5 distinct strain types of Treponema pallidum were identified in these patients, and 9 types were identified in the Seattle nonocular patients. 14d/g was the most common type in both groups. An unusual strain type was detected in a small cluster of ocular syphilis patients in Seattle.

Conclusions

Ocular syphilis is a serious sequela of syphilis. In this preliminary study, clear evidence of a predominant oculotropic strain causing ocular syphilis was not detected. Identification of cases and prompt treatment is critical in the management of ocular syphilis.
Cyanide Suicide After Deep Web Shopping
Authors: Le Garff Erwan , Delannoy Yann , Mesli Vadim , Allorge Delphine , Hédouin Valéry , Tournel Gilles
Published: July 2016

Cyanide is a product that is known for its use in industrial or laboratory processes, as well as for intentional intoxication. The toxicity of cyanide is well described in humans with rapid inhibition of cellular aerobic metabolism after ingestion or inhalation, leading to severe clinical effects that are frequently lethal. We report the case of a young white man found dead in a hotel room after self-poisoning with cyanide ordered in the deep Web. This case shows a probable complex suicide kit use including cyanide, as a lethal tool, and dextromethorphan, as a sedative and anxiolytic substance. This case is an original example of the emerging deep Web shopping in illegal drug procurement.
Sudden Death Due to Bilateral Pulmonary Thromboembolism Following Laparoscopic Cholecystectomy
Authors: Kasuda Shogo , Kudo Risa , Yuui Katsuya , Nakata Masatoshi , Hatake Katsuhiko
Published: July 2016

Cases of sudden death due to pulmonary thromboembolism (PTE) following laparoscopic surgery are very rare. The risk factors for PTE include sex, operation duration, age, obesity, and underlying diseases. The development of thromboprophylaxis according to specific risk factors has contributed to the decrease in postoperative mortality. Here, we describe the case of a 50-year-old patient with sudden death due to PTE at 24 hours after laparoscopic cholecystectomy. The origin of the thrombi were bilateral deep vein thromboses in both the lower extremities. No severe risk factors for PTE were detected in the patient, and pneumatic compression devices were used during the surgery for thromboprophylaxis. We believe that the accumulation of minor risk factors may have contributed to the onset of PTE. Hence, a more cautious assessment of the risk factors for PTE prior to surgery is required in such cases.
Gastric Mucosal Petechial Hemorrhages (Wischnewsky Lesions), Hypothermia, and Diabetic Ketoacidosis
Authors: Clark Kenneth Howard , Stoppacher Robert
Published: July 2016

For more than 100 years since their initial description, gastric mucosal petechial hemorrhages have been discovered at autopsy in cases where environmental hypothermia was determined to be the cause of death. Although these lesions are frequently seen in deaths caused by environmental hypothermia, they can also be seen in cases where hypothermia is not implicated; however, this has been seldom described. We present a series of autopsy cases where hypothermia has been conclusively ruled out as a cause of death, in which Wischnewsky lesions are found. In all of these cases, diabetic ketoacidosis (DKA) was determined to be the proximate cause of death, as confirmed through clinical history, laboratory analysis, and absence of other anatomic or toxicological findings. We provide a mechanism of Wischnewsky lesion formation and how that mechanism relates to both hypothermia and ketoacidosis. Our data show that gastric mucosal petechial hemorrhages are not specific for hypothermia-related deaths, and are likely indicative of a state in which hypothermia and DKA have a common underlying pathophysiology, most likely a coagulopathy. Our data also illustrate that in autopsy cases where Wischnewsky lesions are found, DKA should be seriously considered as the underlying cause of death, particularly in the absence of indications of environmental hypothermia.
Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications*
Authors: Moler Frank W. , Hutchison Jamie S. , Nadkarni Vinay M. , Silverstein Faye S. , Meert Kathleen L. , Holubkov Richard , Page Kent , Slomine Beth S. , Christensen James R. , Dean J. Michael
Published: July 2016

Objective:

To describe outcomes and complications in the drowning subgroup from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial.

Design:

Exploratory post hoc cohort analysis.

Setting:

Twenty-four PICUs.

Patients:

Pediatric drowning cases.

Interventions:

Therapeutic hypothermia versus therapeutic normothermia.

Measurements and Main Results:

An exploratory study of pediatric drowning from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial was conducted. Comatose patients aged more than 2 days and less than 18 years were randomized up to 6 hours following return-of-circulation to hypothermia (n = 46) or normothermia (n = 28). Outcomes assessed included 12-month survival with a Vineland Adaptive Behavior Scale score of greater than or equal to 70, 1-year survival rate, change in Vineland Adaptive Behavior Scale-II score from prearrest to 12 months, and select safety measures. Seventy-four drowning cases were randomized. In patients with prearrest Vineland Adaptive Behavior Scale-II greater than or equal to 70 (n = 65), there was no difference in 12-month survival with Vineland Adaptive Behavior Scale-II score of greater than or equal to 70 between hypothermia and normothermia groups (29% vs 17%; relative risk, 1.74; 95% CI, 0.61–4.95; p = 0.27). Among all evaluable patients (n = 68), the Vineland Adaptive Behavior Scale-II score change from baseline to 12 months did not differ (p = 0.46), and 1-year survival was similar (49% hypothermia vs 42%, normothermia; relative risk, 1.16; 95% CI, 0.68–1.99; p = 0.58). Hypothermia was associated with a higher prevalence of positive bacterial culture (any blood, urine, or respiratory sample; 67% vs 43%; p = 0.04); however, the rate per 100 days at risk did not differ (11.1 vs 8.4; p = 0.46). Cumulative incidence of blood product use, serious arrhythmias, and 28-day mortality were not different. Among patients with cardiopulmonary resuscitation durations more than 30 minutes or epinephrine doses greater than 4, none had favorable Pediatric Cerebral Performance Category outcomes (≤ 3).

Conclusions:

In comatose survivors of out-of-hospital pediatric cardiac arrest due to drowning, hypothermia did not result in a statistically significant benefit in survival with good functional outcome or mortality at 1 year, as compared with normothermia. High risk of culture-proven bacterial infection was observed in both groups.
Comparison of Intraoperative Aminophylline Versus Furosemide in Treatment of Oliguria During Pediatric Cardiac Surgery*
Authors: Onder Ali Mirza , Rosen David , Mullett Charles , Cottrell Lesley , Kanosky Sherry , Grossman Oulimata Kane , Iqbal Hafiz Imran , Seachrist Eric , Samsell Lennie , Gustafson Kelly , Rhodes Larry , Gustafson Robert
Published: July 2016

Objectives:

To determine if intraoperative aminophylline was superior to furosemide to prevent or attenuate postoperative cardiac surgery-associated acute kidney injury.

Design:

Single-center, historical control, retrospective cohort study.

Setting:

PICU, university-affiliated children’s hospital.

Patients:

Children with congenital heart disease in PICU who received furosemide or aminophylline to treat intraoperative oliguria.

Interventions:

Intraoperative oliguria was treated either with furosemide (September 2007 to February 2012) or with aminophylline (February 2012 to June 2013). The postoperative 48 hours renal outcomes of the aminophylline group were compared with the furosemide group. The primary outcomes were acute kidney injury and renal replacement therapy use at 48 hours postoperatively. Surgical complexity was accounted for by the use of Risk Adjustment for Congenital Heart Surgery-1 score.

Measurements and Main Results:

The study involves 69 months of observation. There were 200 cases younger than 21 years old reviewed for this study. Eighty-five cases (42.5%) developed acute kidney injury. The aminophylline group patients produced significantly more urine (mL/kg/hr) during the first 8 hours postoperatively than furosemide patients (5.1 vs 3.4 mL/kg/hr;p= 0.01). The urine output at 48 hours postoperatively was similar between the two groups. There was no difference in acute kidney injury incidence at 48 hours between the aminophylline and furosemide groups (38% vs 47%, respectively;p= 0.29). Fewer aminophylline group subjects required renal replacement therapy compared to the furosemide group subjects (n= 1 vs 7, respectively;p= 0.03). In the multi-variant predictive model, intraoperative aminophylline infusion was noted as a negative predictive factor for renal replacement therapy, but not for cardiac surgery-associated acute kidney injury.

Conclusion:

The intraoperative use of aminophylline was more effective than furosemide in reversal of oliguria in the early postoperative period. There were less renal replacement therapy-requiring acute kidney injury in children in the aminophylline group. Future prospective studies of intraoperative aminophylline to prevent cardiac surgery-associated acute kidney injury may be warranted.
Children and Young Adults Who Received Tracheostomies or Were Initiated on Long-Term Ventilation in PICUs*
Authors: Edwards Jeffrey D. , Houtrow Amy J. , Lucas Adam R. , Miller Rachel L. , Keens Thomas G. , Panitch Howard B. , Dudley R. Adams
Published: July 2016

Objectives:

To characterize patients who received tracheostomies for airway compromise or were initiated on long-term ventilation for chronic respiratory failure in PICUs and to examine variation in the incidence of initiation, patient characteristics, and modalities across sites.

Design:

Retrospective cross-sectional analysis.

Settings:

Seventy-three North American PICUs that participated in the Virtual Pediatric Systems, LLC.

Patients:

PICU patients admitted between 2009 and 2011.

Interventions:

None.

Measurements and Main Results:

Among 115,437 PICU patients, 1.8% received a tracheostomy or were initiated on long-term ventilation; 1,034 received a tracheostomy only, 717 were initiated on invasive ventilation, and 381 were initiated on noninvasive ventilation. Ninety percent had substantial chronic conditions and comorbidities, including more than 50% with moderate or worse cerebral disability upon discharge. Seven percent were initiated after a catastrophic injury/event. Across sites, there was variation in incidence of tracheotomy and initiation of long-term ventilation, ranging from 0% to 4.6%. There also was variation in patient characteristics, time to tracheotomy, number of extubations prior to tracheostomy, and the use of invasive ventilation versus noninvasive ventilation.

Conclusions:

Although the PICU incidence of initiation of tracheostomies and long-term ventilation was relatively uncommon, it suggests that thousands of children and young adults receive these interventions each year in North American PICUs. The majority of them have conditions and comorbidities that impose on-going care needs, beyond those required by artificial airways and long-term ventilation themselves.
Decreasing IV Potassium in Pediatric Cardiac Intensive Care: Quality Improvement Project
Authors: Rhodes Leslie A. , Wall Kevin M. , Abernathy Staci L. , Moellinger Ashley B. , Borasino Santiago , Alten Jeffrey A.
Published: July 2016

Objectives:

IV potassium supplementation is commonly used in the pediatric cardiovascular ICU. However, concentrated IV potassium chloride doses can lead to life-threatening complications. We report results of a quality improvement project aimed at decreasing concentrated IV potassium chloride exposure.

Design:

Retrospective evaluation of a quality improvement project aimed at reducing IV potassium chloride exposure.

Setting:

Pediatric cardiac ICU.

Patients:

All patients admitted to pediatric cardiac ICUs in April 2013 to September 2013 (preprotocol) and October 2013 to April 2014 (postprotocol).

Interventions:

A quality improvement team developed a potassium protocol aimed at maintaining serum potassium levels 3.0–5.5 mEq/L, via algorithm focused on early enteral supplementation. All patients receiving IV diuretics who had a serum potassium level less than 4.5 mEq/L and urine output more than 0.5 mL/kg/hr had protocol initiated with potassium chloride–containing IV fluids or enteral potassium chloride. Concentrated IV potassium chloride infusions were limited to asymptomatic patients with serum potassium less than 2.0 mEq/L and high-risk patients at less than 3.0 mEq/L. Serum potassium levels were measured once daily, and protocolized adjustments were made based on this level and concurrent diuretic therapy.

Measurements and Main Results:

Serum potassium, potassium chloride supplementation, patient cost, fluid administration, and arrhythmia incidence were compared pre and post protocol. Four hundred forty-three admissions were included (234 pre protocol and 209 post protocol). No significant differences were found in demographics. There was no difference in mean morning serum potassium after protocol implementation (3.85 [0.77] mEq/L before protocol and 3.89 [0.75] mEq/L after protocol; p = 0.90). Concentrated IV potassium chloride administration was decreased by 86% (331 vs 47 doses). With protocol, there was decreased incidence in days with one measured episode of hyperkalemia (11 vs 4/1,000 patient-days; p = 0.02) and a trend toward decreased hypokalemia (433 vs 400/1,000 patient-days; p = 0.05). Arrhythmia incidence was similar (p = 0.59).

Conclusions:

Protocolized potassium management in pediatric cardiac intensive care patients decreased concentrated IV potassium chloride exposure and incidence of hyperkalemia. Lower potassium treatment threshold for IV potassium chloride was not associated with increased arrhythmias.
Burden and Outcomes of Severe Pertussis Infection in Critically Ill Infants*
Authors: Straney Lahn , Schibler Andreas , Ganeshalingham Anusha , Alexander Janet , Festa Marino , Slater Anthony , MacLaren Graeme , Schlapbach Luregn J.
Published: July 2016

Objectives:

Despite World Health Organization endorsed immunization schedules, Bordetella pertussis continues to cause severe infections, predominantly in infants. There is a lack of data on the frequency and outcome of severe pertussis infections in infants requiring ICU admission. We aimed to describe admission rates, severity, mortality, and costs of pertussis infections in critically ill infants.

Design:

Binational observational multicenter study.

Setting:

Ten PICUs and 19 general ICUs in Australia and New Zealand contributing to the Australian and New Zealand Paediatric Intensive Care Registry.

Patients:

Infants below 1 year of age, requiring intensive care due to pertussis infection in Australia and New Zealand between 2002 and 2014.

Measurements and Main Results:

During the study period, 416 of 42,958 (1.0%) infants admitted to the ICU were diagnosed with pertussis. The estimated population-based ICU admission rate due to pertussis ranged from 2.1/100,000 infants to 18.6/100,000 infants. Admission rates were the highest among infants less than 60 days old (p < 0.0001). Two hundred six infants (49.5%) required mechanical ventilation, including 20 (4.8%) treated with high-frequency oscillatory ventilation, 16 (3.8%) with inhaled nitric oxide, and 7 (1.7%) with extracorporeal membrane oxygenation. Twenty of the 416 children (4.8%) died. The need for mechanical ventilation, high-frequency oscillatory ventilation, nitric oxide, and extracorporeal membrane oxygenation were significantly associated with mortality (p < 0.01). Direct severe pertussis–related hospitalization costs were in excess of USD$1,000,000 per year.

Conclusions:

Pertussis continues to cause significant morbidity and mortality in infants, in particular during the first months of life. Improved strategies are required to reduce the significant healthcare costs and disease burden of this vaccine-preventable disease.
A Large Case Series of Acute Pediatric Methotrexate Ingestions
Authors: Hensley Matthew D. , Bebarta Vikhyat S. , Borys Douglas J.
Published: July 2016

Objective

Significant adverse effects after acute pediatric methotrexate (MTX) exposures have been limited to parenteral exposures. Treatment recommendations for pediatric MTX exposures do not differentiate between routes of exposure. We report the incidence of significant clinical effects and drug-specific treatments reported in a large series of acute, pediatric MTX ingestions.

Methods

Poison center records of all MTX ingestions by patients younger than 17 years during 2000 to 2005 were collected from 6 poison centers. The cases included all MTX ingestions including those with additional substances. One trained reviewer, blinded to the study purpose, used a standardized data collection form to extract study data. Missing or conflicting data were reconciled with predetermined process.

Results

Forty-seven cases were documented for 6 years, 42 (89%) of which were unintentional. Thirty-six percent (17/47) were male. The mean age for the unintentional ingestions was 3.7 years (range, 20 days–17 y; median, 2 y). Five cases (11%) were intentional suicidal ingestions in teenagers. The mean dose in acute, unintentional ingestions (AUIs) in all children and in children younger than 6 years was the same, 8 mg (range, 2.5–17.5 mg). Eleven patients (23%) had follow-up greater than 12 hours. No patient with an AUI developed MTX-induced sedation, hepatotoxicity, renal insufficiency, seizures, or bone marrow suppression. Three patients with an AUI received folinic acid, but no patients in this group received sodium bicarbonate or hemodialysis. One patient with an intentional suicidal exposure developed hepatotoxicity, but the patient also ingested a toxic dose of acetaminophen and valproate. Hemodialysis was performed once on this patient. No patient died.

Conclusions

Acute pediatric MTX ingestion is uncommon. Methotrexate-induced seizure, renal failure, hepatic injury, and sedation were not documented in our series. Supportive care and observation only should be considered the mainstay of treatment of pediatric AUIs. Prospective verification of our findings is warranted.
Essentials of Pediatric Emergency Medicine Fellowship
Authors: Mittiga Matthew R. , Nagler Joshua , Eldridge Charles D. , Ishimine Paul , Zuckerbraun Noel S. , McAneney Constance M.
Published: July 2016

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.
A Case of Stage 4B Seromucinous Ovarian Borderline Tumor With Endometriosis and Review of the Literature
Authors: Newton Claire L. , Brockbank Elly , Singh Naveena , Faruqi Asma
Published: July 2016

Ovarian mucinous borderline tumors are traditionally divided into 2 morphologic groups: endocervical type, also known as seromucinous, and intestinal type. We present a case of stage 4B seromucinous ovarian borderline tumor with endometriosis and review the literature. At the time of writing, this is believed to be the first case of a seromucinous borderline tumor reported at such an advanced stage.
The Chemotherapy Response Score (CRS): Interobserver Reproducibility in a Simple and Prognostically Relevant System for Reporting the Histologic Response to Neoadjuvant Chemotherapy in Tuboovarian High-grade Serous Carcinoma
Authors: Said Ian , Böhm Steffen , Beasley Joanne , Ellery Peter , Faruqi Asma Z. , Ganesan Raji , Hirschowitz Lynn , Jeetle Sharanpal , Leen Sarah Lam Shang , McCluggage W. Glenn , McDermott Jacqueline , Merard Reena , Millner Thomas O. , Trevisan Giorgia , Vella Jo , Gilks C. Blake , Singh Naveena
Published: July 2016

A 3-tier histopathologic scoring system, the chemotherapy response score (CRS), was previously devised for reporting the histologic response to neoadjuvant chemotherapy in interval debulking surgery specimens of stage IIIc/IV tuboovarian high-grade serous carcinoma. This has been shown to predict the outcome and offer additional information to other methods of assessing the treatment response. In the present study, the reproducibility of this scoring system was assessed by determining the interobserver agreement among reporting pathologists. A total of 5 groups each comprising 3 pathologists with different levels of expertise were selected. The participants underwent an online tutorial on how to apply the CRS system. 40 cases (38 cases in 2 appraiser groups) were scored individually by each of the 15 pathologists. The interobserver reproducibility was calculated using Fleiss’ κ, Kendall’s coefficient of concordance, and the absolute agreement between (a) individual pathologists within 1 group, (b) with the majority score agreement between all groups, and (c) with all individual scores. The CRS system was found to be highly reproducible among all the pathologists’ groups (κ=0.761). The agreement in identifying the group of patients with the best response to chemotherapy was exceptionally high (κ=0.926). We conclude that CRS has a high interobserver reproducibility, especially in identifying the subgroup of patients with the best chemotherapy response, justifying its inclusion in clinical trials and reporting practice.
Comprehensive Analysis of PAX8 Expression in Epithelial Malignancies of the Uterine Cervix
Authors: Wong Serena , Hong Wei , Hui Pei , Buza Natalia
Published: July 2016

Immunohistochemistry for transcription factor PAX8 (paired box gene 8) has recently emerged as a powerful tool in the differential diagnosis of gynecologic malignancies, especially when encountered at a metastatic site. Previous studies have shown PAX8 expression in the majority of ovarian and endometrial carcinomas; however, data regarding PAX8 expression in cervical tumors are limited. In this study PAX8 expression was evaluated in 136 epithelial malignancies of the uterine cervix—including 103 squamous cell carcinomas (SCC), 20 adenocarcinomas of usual type, 6 endometrioid adenocarcinomas, and 7 adenosquamous carcinomas—on tissue microarray slides. PAX8 immunopositivity was defined as at least weak nuclear staining in >5% of tumor cells. The majority of SCC were PAX8 negative (92%; 95/103), whereas among the endocervical adenocarcinomas PAX8 was positive in 70% (14/20) of the usual type and in 83% (5/6) of the endometrioid-type tumors. PAX8 expression was observed in 29% (2/7) of adenosquamous carcinomas. We conclude that PAX8 immunostain is negative in most cervical SCC and is less frequently expressed in endocervical adenocarcinomas as compared with the previously reported high sensitivity for ovarian and endometrial adenocarcinomas. When evaluating possible primary sites of a metastatic lesion, a negative PAX8 immunostain does not rule out common cervical epithelial malignancies.