Parental manual ventilation in resource-limited settings: an ethical controversy.

Lower respiratory tract infections are a leading cause of paediatric morbidity and mortality worldwide. Children in low-income countries are disproportionately affected. This is in large part due to limitations in healthcare resources and medical technologies. Mechanical ventilation can be a life-saving therapy for many children with acute respiratory failure. The scarcity of functioning ventilators in low-income countries results in countless preventable deaths. Some hospitals have attempted to adapt to this scarcity by using hand-bag ventilation, as either a bridge to a mechanical ventilator, or until clinical improvement occurs rendering mechanical ventilation no longer necessary. In instances of hand-bag ventilation, an endotracheal tube is first placed. Family members are then asked to play the role of a ventilator, manually compressing a bag repeatedly to inflate the child's lungs. This approach is fraught with numerous ethical challenges. A careful examination of the data and a nuanced approach to the ethical considerations are imperative. Ethical arguments in support of and in opposition to allowing parental hand-bag ventilation are explored, including the best interests of the child, the child's right to an open future, beneficence and parental protection, legitimising substandard care, and finally, contextual concerns. An algorithmic, potentially ethically permissible approach to parental participation in manual ventilation is proposed.

Better to light a candle: Arthur Barsky and global plastic surgery.

Plastic and reconstructive surgery has had a long history with international humanitarian efforts. As the field of global surgery continues to gain momentum in academic centers throughout the world, the role of the surgical subspecialist in the public health infrastructure of low-resource communities has also begun to gain a new sense of wonder and importance. Arthur Barsky, Jr was arguably one of the most influential forefathers of global plastic surgery. Throughout his notable career spanning most of the 20th century, Barsky remained dedicated to delivering plastic and reconstructive surgical care to the disadvantaged worldwide, as well as educating others to do the same. Although he was not the first surgeon with an interest in global health, Barsky's work was unique and influential in its originality, magnitude, and scope. An appreciation and understanding of Barsky's groundbreaking work will help inform the future development of sustainable surgical systems in resource-poor settings.

Attitudes towards involving children in decision-making surrounding lung transplantation.

BACKGROUND: Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of making medical decisions at a young age, yet no standardized approaches have been developed for involving children in these decisions. METHODS: This is a single-center survey study investigating the attitudes of pediatric pulmonologists towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, reconciliation of parent-child discordance, and utility of ethics and psychiatry consultation services. RESULTS: The majority of pediatric pulmonologists at this center believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physicians are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations. CONCLUSION: Involvement of children with cystic fibrosis in SDM is broadly supported but inconsistently implemented. Despite evidence that children with chronic disease may have decisional capacity at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.

A Practical Approach to Severe Asthma in Children.

Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.

Ceftaroline pharmacokinetics and pharmacodynamics in patients with cystic fibrosis.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a prevalent pathogen in patients with cystic fibrosis (CF) associated with increased morbidity. Ceftaroline fosamil is an intravenous (IV) cephalosporin with activity against MRSA. There are minimal data regarding dosing in the CF population. The objective of this study was to determine the pharmacokinetic and pharmacodynamic profile of IV ceftaroline in patients with CF. METHODS: We conducted a single-center prospective study of children and young adults with CF receiving ceftaroline (15mg/kg IV up to 600mg every 8h) as part of treatment for a CF pulmonary exacerbation between June 2016 and April 2017. Seven patients were enrolled for a total of 10 treatment courses. For each treatment course, up to 8 plasma samples were assayed for ceftaroline using ultra-high performance liquid chromatography with mass spectrometry. Maximum plasma concentration, systemic clearance, and elimination half-life were calculated. The area under the curve (AUC) above the minimum inhibitory concentration (MIC) and the percent time above the MIC (%fT>MIC) were determined for each subject using MICs of 0.5, 1, and 2µg/mL and the measured MIC if available. RESULTS: The mean (SD) age for the 7 patients was 20.3 (8.0) years. Mean (SD) maximum plasma concentration of ceftaroline was 22.7 (9.6) µg/mL, systemic clearance 7.9 (3.3) L/h, and half-life 1.1 (0.4) hours. Using a MIC of 1 µg/mL, accepted as the MIC 90 of MRSA isolates, AUC above MIC mean (SD) was 53.6 (19.5) µg·h/mL, mean (SD) %fT>MIC was 75.7 (10.4), and all subjects had >60%fT>MIC. CONCLUSIONS: In this cohort of CF patients, mean ceftaroline half-life was 1.1h, which is notably lower than the general population. The dosing regimen studied, which exceeds the recommended dosing in the non-CF population, was adequate to achieve >60% time above the MIC in all patients.

Incident Stenotrophomonas maltophilia infection and lung function decline in cystic fibrosis.

OBJECTIVES: To determine whether incident detection of Stenotrophomonas maltophilia (SM) in patients with cystic fibrosis (CF) is associated with accelerated lung function decline and increased hospitalizations and to determine whether this effect is more pronounced in individuals with subsequent chronic infection. METHODS: We performed a longitudinal, retrospective single-center, pre-post study of 88 patients with CF, ages 6-51 years, with first positive respiratory culture for SM between 2008 and 2014. Rate of decline in FEV1 and hospitalization rates prior to and following incident SM infection were analyzed using segmented regression analysis of interrupted time series. RESULTS: Mean (SD) age was 17.4 (9.2) years and the mean (SD) FEV1 % predicted at acquisition was 90.0% (25.2). A total of 44% developed chronic SM infection. In regression analysis adjusted for clinical and demographic factors, there was worsening of the mean annual decline in FEV1 % predicted from -1.79 (95%CI: -2.43, -1.15) pre-acquisition to -2.14 (95%CI: -2.61, -1.67) post-acquisition (P = 0.005). A significant change was observed in those with either subsequent intermittent or chronic infection. The mean annual hospitalization rate increased significantly in the subgroup with chronic infection from 0.46 (95%CI: 0.33, 0.60) to 0.88 (95%CI: 0.68, 1.07) (P = 0.007). CONCLUSIONS: In this single-center cohort, acquisition of SM in CF was associated with an acceleration in lung function decline. Among those with chronic colonization, acquisition was also associated with increased hospitalization rates.

Improving glycemic control in medical inpatients: a pilot study.

BACKGROUND: Inpatient hyperglycemia is associated with poor patient outcomes. Current guidelines recommend that in an inpatient non-ICU setting there be treatment to achieve a glucose level below 180 mg/dL. METHODS: Objectives of this prospective quality-improvement pilot study were to implement a subcutaneous insulin protocol on a general medicine service, to identify barriers to implementation, and to determine the effect of this protocol on glycemic control. Eighty-nine patients with a preexisting diagnosis of type 2 diabetes or inpatient hyperglycemia were eligible. Study outcomes included resident acceptance of the protocol, insulin-ordering practices, and mean rate of hyperglycemia (glucose > 180 mg/dL) per person. Results were compared with those of a previously conducted observational study. RESULTS: Residents agreed to use the protocol in 56% of cases. Reasons for declining the protocol included severity of a patient's other disease states, desire to titrate oral medications, and fear of hypoglycemia. Basal and nutritional insulin were prescribed more often in the pilot group compared with at baseline (64% vs. 49% for basal, P = .05; 13% vs. 0% for nutritional, P < .001). Basal insulin was started after the first full hospital day in 42% of patients, and only one-third of patients with any hypo- or hyperglycemia had any subsequent changes in their insulin orders. The mean rate of hyperglycemia was not significantly different between groups (31.6% of measurements per patient vs. 33.3%, P = .85). CONCLUSIONS: Adherence to a new inpatient subcutaneous insulin protocol was fair. Barriers included fear of hypoglycemia, delays in starting basal insulin, and clinical inertia. Quality improvement efforts likely need to target these barriers to successfully improve inpatient glycemic control.

Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.

BACKGROUND: Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients. OBJECTIVE: To determine the current state of glucose management on an academic hospitalist service and the relationship between insulin-ordering practices and glycemic control. DESIGN: Prospective cohort study. SETTING: Hospitalist-run general medicine service of an academic teaching hospital. PATIENTS: 107 consecutive patients with diabetes mellitus or inpatient hyperglycemia. MEASUREMENTS: We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patient-day. RESULTS: The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid- or short-acting insulin was ordered for 4% of patients. Sixty-five percent of patients who had at least 1 episode of hyper- or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of sliding-scale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patient-day. CONCLUSIONS: Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia.