Comparison and Agreement between Cardiovascular Computed Tomography-Derived Mid-Diastolic and End-Diastolic Ventricular Volume in Patients with Congenital Heart Disease.

Prospective electrocardiogram (ECG)-triggered cardiovascular computed tomography (CCT) is primarily utilized for anatomical information in congenital heart disease (CHD) and has not been utilized for calculation of the end-diastolic volume (EDV); however, the mid-diastolic volume (MDV) may be measured. The objective of this study was to evaluate the feasibility and agreement between ventricular EDV and MDV. 31 retrospectively ECG-gated CCT were analyzed for the study of the 450 consecutive CCT. CCT images were processed using syngo.via with automatic contouring followed by manual adjustment of the endocardial borders of the left ventricles (LV) and right ventricles (RV) at end-diastolic and mid-diastolic phase (measured at 70% of cardiac cycle). The correlation and agreements between EDV and MDV were demonstrated using Spearman rank coefficient and intraclass correlation coefficient (ICC), respectively. Mean age ± SD was 28.8 ± 12.5 years, 19 were male (61.3%) and tetralogy of Fallot (TOF) was the most common diagnosis (58.1%), 35% (11/31) patients with a pacemaker, ICD or other such contraindication for a CMRI, 23% (7/31) with claustrophobia, and 6.5% (2/31) with developmental delay with refusal for sedation did not have a previous CMRI. The mean ± SD indexed LV EDV and LV MDV were 91.1 ± 24.5 and 84.8 ± 22.3 ml/m2, respectively. The mean ± SD indexed RV EDV and RV MDV were 136.8 ± 41 and 130.2 ± 41.5 ml/m2, respectively. EDV and MDV had a strong positive correlation and good agreement (ICC 0.92 for LV and 0.95 for RV). This agreement was preserved in a subset of patients (21) with dilated RV (indexed RV EDV z-score > 2). Intra-observer reliability (0.97 and 0.98 for LV and RV MDV, respectively) and inter-observer reliability (0.96 and 0.90 for LV and RV MDV, respectively) were excellent. In a select group of patients with CHD, measuring MDV by CCT is feasible and these values have good agreements with EDV. This may be used to derive functional data from prospectively ECG-triggered CCT studies. Further large-scale analysis is needed to determine accuracy and clinical correlation.

Sociodemographic Disparities in Ambulatory Pediatric Telemedicine Utilization During COVID-19.

Objective: Few studies have examined sociodemographic disparities in ambulatory pediatric telemedicine utilization during the coronavirus disease 2019 pandemic. We aimed to (1) assess disparities in telemedicine visit completion during the first 6 weeks of the pandemic in 2020 and (2) determine if these disparities were significantly different from those present in 2019, when all visits occurred in person. Methods: We compared sociodemographic characteristics of patients with successful versus unsuccessful telemedicine visits from March 10, 2020 to April 18, 2020, using generalized linear mixed models. We performed the same analysis for in-person visits from the same period in 2019. We tested for differences across years using interaction terms in a combined 2019-2020 model. Results: Of 3,639 telemedicine visits scheduled, 3,033 (83.3%) were successful. In 2020, Black/African American race was significantly associated with lower odds of telemedicine visit success (odds ratio 0.65 [95% confidence interval 0.49-0.87]) compared with White race, after adjusting for age, gender, ethnicity, insurance type, visit timing, visit specialty, social vulnerability index, and internet access. In 2019, racial identity other than White was significantly associated with lower odds of in-person visit success than White, as was public insurance compared with private. In the full 2019-2020 model, in-person visits (2019) had lower odds of success than telemedicine visits (2020), and neither race, insurance type, nor any other sociodemographic characteristic had significant interactions with year. Conclusions: Racial disparities were evident in telemedicine utilization early in the pandemic; however, these disparities were not significantly different from those seen in 2019, when all visits were in person. Furthermore, telemedicine may improve access to care overall, despite having no significant impact on inequity. Efforts to eliminate racial disparities in ambulatory pediatric health care utilization are necessary across visit modalities.

Does Compliance with Resuscitation Practice Guidelines Differ Between Pediatric Intensive Care Units and Cardiac Intensive Care Units?

Objective: Hospitalized children with cardiac disease have the highest rate of cardiac arrest compared to other disease types. Different intensive care unit (ICU) models exist, but it remains unknown whether resuscitation guideline adherence is different between cardiac ICUs (CICU) and general pediatric ICUs (PICU). We hypothesize there is no difference in resuscitation practices between unit types. Design: Retrospective observational study. Setting: The American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) registry. Patients: Children < 18 years old with medical or surgical cardiac disease who had cardiopulmonary arrest from 2014 to 2018. Intervention: None. Measurements and Main Results: Events were assessed for compliance with GWTG-R achievement measures of time to first chest compressions ≤ 1 min, time to intravenous/intraosseous epinephrine ≤ 5 min, time to first shock ≤ 2 min for ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), and confirmation of endotracheal tube placement. Additional practices were evaluated for consistency with Pediatric Advanced Life Support (PALS) recommendations. Eight hundred and eighty-six patients were evaluated, 687 (79%) in CICUs and 179 (21%) in PICUs. 484 (56%) had surgical cardiac disease. There were no differences in GWTG-R achievement measures or PALS recommendations between ICU types in univariable or multivariable models. Amiodarone, lidocaine, and nonstandard medication use did not differ by unit type. Extracorporeal cardiopulmonary resuscitation (ECPR) was more common in CICUs for both medical (16% vs 7%) and surgical (25% vs 2.5%) categories (P < .0001). Conclusions: Resuscitation compliance for patients with cardiac disease is similar between CICUs and PICUs. Patients were more likely to receive ECPR in CICUs. Additional study should evaluate how ICU type affects arrest outcomes in children with cardiac disease.

The safety of COVID-19 vaccination in immunocompromised children and young adults with immune-mediated inflammatory disease.

AIM: To assess safety of COVID-19 vaccination in paediatric patients with immune-mediated inflammatory disease (IMID). METHODS: Subjects of 5-21 years of age with IMID who received at least one COVID-19 vaccine completed electronic surveys after each vaccine to assess side effects within 1 week of vaccination, current medications and COVID-19 testing after vaccination. Charts were reviewed for COVID-19 polymerase chain reaction and IgG response to SARS-CoV-2 spike protein results and for disease flare during the study period. RESULTS: Among 190 enrolled subjects, 71% were female, with median age 17 (range 6-21) years. The most common diagnosis was juvenile idiopathic arthritis/rheumatoid arthritis (55%). 78% of subjects were taking immunosuppressive medication. At least one side effect was reported in 65% of subjects after any dose of the vaccine; with side effects in 38%, 53% and 55% of subjects after the first, second and third vaccine doses, respectively. The most common side effects were injection site pain (59%), fatigue (54%) and headache (39%). No anaphylaxis or myocarditis was reported. Three subjects (2%) experienced disease flare. CONCLUSION: In our cohort of paediatric patients with IMID, observed side effects were found to be mild and disease flare rates were found to be low following COVID-19 vaccination.

Inflammatory myofibroblastic tumor: A multi-institutional study from the Pediatric Surgical Oncology Research Collaborative.

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000 to 2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. One hundred and eighty-two patients were identified with median age of 11 years. Thirty-three percent of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%) and constitutional symptoms (20%). Median tumor size was 3.9 cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. Seven percent of patients had distant disease at diagnosis. Ninety-one percent of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. Twelve percent of patients received an ALK inhibitor. Sixty-six percent of surgical patients had complete resection, with 20% positive microscopic margins and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival was 95% and 5-year event-free survival was 80%. Predictors of recurrence included respiratory symptoms, tumor size and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted.

Documented Viral Illness at the Time of Splenic Sequestration Does Not Affect the Odds of Recurrence in Children With Sickle Cell Disease.

This retrospective study investigates the relationship between the presence of a documented viral infection in children with sickle cell disease during their first splenic sequestration crisis and their odds of recurrence. Forty-eight children were admitted to our hospital between 2008 and 2018 with a splenic sequestration crisis. Thirty-six had respiratory viral panels done on admission, 13 of whom were positive. Two additional children were diagnosed with parvovirus B19 infection by serology. The recurrence rate was 52% (17/33) for those deemed negative for viral illness compared with 33% (5/15) among those with a positive documented viral illness, which was not statistically different (P=0.35). HbSC genotype decreased, and reticulocytosis increased the odds of recurrence. Further research is needed to substantiate these findings.

Retrospective study comparing success rates of lumbar puncture positions in infants.

BACKGROUND: A lumbar puncture (LP) is performed in the emergency room for diagnostic purposes; unsuccessful or traumatic LPs can complicate decision making. The sitting position has a larger interspinous process compared to lateral recumbent and is safer in sick neonates at risk for cardiac and respiratory instability. PURPOSE: Our study aims to determine which position (lateral recumbent or sitting) is associated with a greater likelihood of successful lumbar puncture in infants <3 months when performed in the emergency room. BASIC PROCEDURES: This is a retrospective chart review in infants aged <3 months who had a LP performed in a pediatric emergency room. The primary outcome was the rate of successful LPs, defined as obtaining adequate CSF to send for all studies. The secondary outcome was the proportion of atraumatic LPs by position, defined as <500 RBCs or < 10,000 RBCs. MAIN FINDINGS: A total of 557 charts were reviewed with 116 in the sitting position and 441 in the lateral recumbent position. The primary outcome of adequate CSF fluid collection was not significantly different between groups (63% sitting position versus 58% lateral recumbent position; p = 0.22). In addition, the proportion of atraumatic LPs showed no significant difference regardless of RBC cutoff (<500 RBCs p = 0.83, <10,000 RBCs p = 0.60). PRINCIPLE CONCLUSIONS: This study found no evidence that there is a difference in rate of LP success nor the proportion of traumatic LP in infants less than 3 months of age when positioned in the sitting position compared to the lateral recumbent position.

Assessing the Variability of Antibiotic Management in Patients With Open Hand Fractures Presenting to the Pediatric Emergency Department.

OBJECTIVES: Open hand fractures may be difficult to recognize and treat. There is variability in management and administration of antibiotics for these types of injuries. Unlike open long bone fractures, there is no standardized protocol for antibiotic administration for open hand fractures in children. The objective of this study is to assess the variability of antibiotic management of open hand fractures in children. METHODS: We performed a retrospective chart review at a tertiary hospital in New York of patients with hand injuries between ages 0 and 18 years presenting to the emergency department during January 2019 and December 2020. Patient encounters were reviewed for open fractures of the hand. Descriptive statistics were included for demographic and physical characteristics. RESULTS: There were 80 encounters with open hand fractures, of which the most common being tuft fractures (77.5%). The mean age was 7.6 years (SD, 4.7 years) with male predominance (58.8%). Crush injuries were the most common mechanism of injury (78.8%). Bedside repair was performed on 62 encounters (77.5%), of which 45 (72.5%) required nail bed repair, 56 (90.3%) required suturing, and 24 (38.7%) required reduction. Antibiotics were given to 62 (77.5%) encounters, most commonly oral cefalexin (45.2%), oral amoxicillin-clavulanic acid (27.4%), and intravenous cefazolin (14.5%). Median time to antibiotics from emergency department registration to administration was 150 minutes (interquartile range, 92-216 minutes). Antibiotic prescriptions were sent for 71 encounters (88.8%). Seventy seven (96.3%) of the encounters were discharged home. CONCLUSIONS: Pediatric open hand fractures have a variability of type and timing to antibiotics. Future initiatives should attempt to create standardized guidelines for management of open hand fractures.

"Code Green Active" Curriculum: Implementation of an Educational Initiative to Increase Awareness of Active Shooter Protocols Among Emergency Department Staff.

BACKGROUND: There has been an increase in violent acts against hospital employees, including active shooter events. Emergency department (ED) staff must be able to respond to these events efficiently to ensure the safest possible outcome. However, few in our ED were aware of our hospital's active shooter protocol. We aimed to increase staff knowledge of and confidence in these guidelines. METHODS: We developed and implemented a 7-week spiral curriculum using the Kern model of curriculum development. Each week, a segment of the hospital active shooter protocol was featured. Multimodal instructional methods including posters, instruction at daily team huddles, descriptions in the weekly division newsletter, and email summaries were used.A 10-question assessment was administered to ED staff both before and after the implementation of our curriculum. During both assessments, staff were asked to rate their confidence in both knowledge of and ability to follow hospital active shooter guidelines. RESULTS: There were 95 and 102 participants in the preintervention and postintervention periods, respectively.The median proportion of correct answers on the knowledge assessment increased when comparing preintervention with postintervention performances (P < 0.05).Staff confidence in both knowledge of and ability to follow active shooter protocols increased after the implementation of our curriculum (P < 0.05). CONCLUSIONS: Our 7-week curriculum resulted in improved knowledge of and confidence in hospital active shooter protocols among ED staff. Given that our sample was an unpaired convenience sample, inferences from our analysis were limited. Tabletop simulations are currently underway to further reinforce and clarify concepts.

Outcomes for Children With a Nonvisualized Appendix on Ultrasound.

OBJECTIVES: Oftentimes while pursing the diagnosis of appendicitis, an ultrasound cannot visualize the appendix, and physicians must utilize other resources for evaluation. The primary objective of this study was to determine if there was a lower rate of appendicitis when the appendix was not visualized on ultrasound. Furthermore, we assessed the importance of specific clinical predictors in this population. METHODS: We conducted a retrospective chart review of all children who presented to our pediatric emergency department from 2011 to 2013 and had an abdominal ultrasound. We identified total numbers of ultrasounds with a nonvisualized appendix and then assessed follow-up for a randomly selected group of patients. We performed logistic regression to assess the predictive value of different clinical factors. RESULTS: A total of 3245 ultrasounds were analyzed, and in 54% of these, the appendix was nonvisualized. In total, 28% of the total patients and 11.9% of patients who received a nonvisualized ultrasound had appendicitis (95% confidence interval [CI], 8.3%-16.2%). Among those patients who had follow-up studies performed during the same visit, 21.2% had appendicitis (95% CI, 14.9%-28.8%), and of those discharged without a diagnosis, 1.5% had appendicitis (95% CI, 0.2%-5.4%). Male sex, leukocytosis, and an elevated absolute neutrophil count were each significantly associated with appendicitis after a nonvisualized appendix on ultrasound. CONCLUSIONS: A significant proportion of patients with suspected appendicitis who had an initial nonvisualized appendix on ultrasound were ultimately diagnosed with appendicitis. Clinicians must be vigilant about pursuing a definitive diagnosis if an initial ultrasound is nondiagnostic.

A pilot study to screen for poor academic performance in children with sickle cell disease in the outpatient setting.

BACKGROUND: Children with sickle cell disease (SCD) are at risk for neurocognitive deficits, which can lead to effects on academic performance and later job attainment. However, screening in children at high risk for poor academic performance (PAP) in a clinic setting has been limited. The goal was to identify young children with SCD at high risk for PAP via administration of a standardized screening tool at the clinic visit. PROCEDURE: Parents of 20 patients were asked to complete the Behavior Assessment System for Children, 3rd edition (BASC-3) Parent Rating Scale. Children ages six to nine years and all SCD genotypes were included. Those patients who scored at least 1 standard deviation below the mean were considered high risk. Statistics was used to associate demographic, academic, and laboratory data with risk status (RS). RESULTS: Four of 20 patients (20%) were found to be at risk by the BASC-3. A significant association was found between those with a history of PAP and RS (P = 0.001). A trend toward association was found between baseline hemoglobin, reticulocyte count, and RS. Children not at risk had a higher hemoglobin level and lower reticulocyte count (P = 0.37 and P = 0.20, respectively). Those on hydroxyurea were significantly less likely to score as at risk (P = 0.014), whereas those with siblings may be at greater risk (P = 0.037). CONCLUSION(S): A parent-directed screening tool may identify children with SCD in need of additional school support. Further prospective studies are necessary to understand correlations found between hemoglobin, reticulocyte count, and hydroxyurea treatment and risk for PAP.

Novel Assessment of Accessory Pathway Function in Patients with Wolff-Parkinson-White Syndrome.

Surrogates for the shortest pre-excited R-R interval in atrial fibrillation (SPERRI) such as the accessory pathway effective refractory period (APERP) and shortest pre-excited paced cycle length (SPPCL) are flawed assessments of accessory pathway function in patients with WPW. Multi-extrastimulus pacing may have the theoretical advantage of more accurately mimicking the clinical reality of atrial fibrillation and thus may serve to better assess accessory pathway function. This cross-sectional study included 25 consecutive patients, aged ≤ 18 years, undergoing electrophysiology study for WPW. The longest S1S2, S2S3, S3S4 coupling intervals at which the antegrade AP refractoriness occurred, SPERRI, and SPPCL were recorded. Induction of atrial fibrillation was attempted in all patients and induced in 8 (32%, 4 SPERRIbaseline (265 ms ± 61 ms), 4 SPERRIIsuprel (258 ms ± 41 ms)). At baseline, the lower value of the S3ERP or S4ERP (274 ms ± 52 ms) was lower than the SPPCL (296 ms ± 54 ms, p < 0.0001) and APERP (296 ms ± 41 ms, p < 0.0001). More patients had S3ERP or S4ERP ≤ 250 ms (12/25, 48%) compared to those with APERP ≤ 250 ms (2/25 8%), p = 0.0016), SPPCL 5/24, 20%), p = 0.008 or either (6/25, 24%), p = 0.0143). With Isuprel, the lower value of the S3ERP or S4ERP (221 ms ± 36 ms) trended to be lower than the APERP (252 ms ± 36 ms, p = 0.0001) and the SPPCL (266 ms ± 57 ms, p = 0.001). With Isuprel, there was no statistical difference in the proportion of patients with S3ERP or S4ERP < 250 ms (12/16, 75%) compared to those with APERP ≤ 250 ms ((9/16, 56%), p = 0.08), SPPCL ≤ 250 ms ((9/16, 56%), p = 0.08), or either ((10/16, 63%), p = 0.16). Multi-extrastimulus pacing protocols demonstrate that accessory pathways are less refractory than as defined by single extrastimulus pacing and straight decremental pacing.

Maximizing the Use of Scoring Systems in the Prediction of Outcomes in Acute Pancreatitis.

BACKGROUND/AIMS: No single classification system has so far effectively predicted the severity for Acute Pancreatitis (AP). This study compares the effectiveness of classification systems: Original Atlanta (OAC), Revised Atlanta (RAC), Determinant based classification (DBC), PANC 3, Harmless AP Score (HAPS), Japanese Severity Score (JSS), Symptoms Nutrition Necrosis Antibiotics and Pain (SNNAP), and Beside Index of Severity for AP (BISAP) in predicting outcomes in AP. METHODS: Scores for BISAP, Panc 3, HAPS, SNNAP, OAC, RAC, and DBC were calculated for 221 adult patients hospitalized for AP. Receiver Operating Characteristic curve analysis and Akaike Information Criteria were used to compare the effectiveness of predicting need for surgery, intensive care unit (ICU) admission, readmission within 30 days, and length of hospital stay. RESULTS: Both the RAC and the DBC strongly predict the length of hospital stay (p < 0.0001 for both) and ICU admission (p < 0.0001 for both). Additionally, both BISAP and PANC 3 showed weak predictive capacity at identifying length of stay and ICU admission. CONCLUSIONS: We suggest that BISAP and PANC3 be obtained within the initial 24 h of hospitalization to offer an early prediction of length of stay and ICU admission. Subsequently, RAC and DBC can offer further information later in the course of the disease.

Infections of Prosthetic Grafts and Patches Used for Infrainguinal Arterial Reconstructions.

BACKGROUND: Prosthetic grafts are often used as alternative conduits in patients with peripheral vascular disease who do not have an adequate autologous vein for bypass. Prosthetic grafts, unfortunately, carry an increased risk of infection and are associated with increased morbidity and mortality. The goal of this study was to identify potential risk factors and subsequent outcomes associated with lower extremity prosthetic graft infections. METHODS: Two hundred seventy-two lower extremity prosthetic bypasses and patches were performed at an academic medical center between 2014 and 2016. A retrospective review of patients' demographics, comorbidities, indication for surgery, type of procedures performed, and procedural characteristics was conducted. Outcomes, including limb loss and mortality, were analyzed. RESULTS: Forty-three (15.8%) patients with graft infections were identified during a median follow-up of 668 days (interquartile range [IQR] = 588). The median time to graft infection was 43 days (IQR = 85) with Staphylococcus being the most common bacteria cultured. Infections were associated with a 30.2% rate of limb loss and a 34.9% rate of mortality. The risk of infection was 2.4 times greater among those with a history of redo surgery (95% confidence interval [CI] of the hazard ratio [HR]: 1.3, 4.3) and 2.1 times greater in women (95% CI: 1.1, 3.8), by multivariable statistics. A 1 g/dL increase in albumin level was associated with a 33.5% decrease in hazard of infection (HR: 0.67, 95% CI: 0.46, 0.96) in the multivariable model. The estimated cumulative incidence of infection for female patients with hypertension and mean albumin of 3.36 undergoing redo surgery was 19.4% at 30 days after surgery (95% CI: 10.6, 35.6) and 39.9% at 1 year (95% CI: 26.8, 59.3). CONCLUSIONS: Female gender, redo surgery, and malnutrition are associated with increased risk of prosthetic graft infections leading to a high rate of limb loss and mortality. Endovascular interventions and bypasses with vein conduits should be considered in these patients.

Reasons for Chemotherapy Refusal or Acceptance in Older Adults With Cancer.

OBJECTIVES: The majority of Americans diagnosed as having cancer are older than 65 years. They are, however, less likely than younger patients to receive chemotherapy. Our study aimed to better understand the specific reasons for acceptance or refusal of chemotherapy in older adults with cancer. METHODS: An anonymous cross-sectional survey was distributed during a 6-month study period in a cancer center and an outpatient geriatric medicine faculty practice to patients at least 50 years old with cancer or to their family members. Data collected included reasons for refusal or acceptance, stage/type of cancer, and demographics. The association between chemotherapy refusal or initiation and these factors was assessed using the Fisher exact test. RESULTS: Among the 37 respondents meeting the inclusion criteria, 78.4% were patients and 21.6% were family members. The following factors were significantly associated with chemotherapy decision: perceived chemotherapy benefit (P < 0.001), trust in the doctor's recommendation (P = 0.013), social support (P = 0.018), marital status (P < 0.001), sex (P = 0.037), race/ethnicity (P = 0.021), and whether respondents had a family member or friend who had previously received chemotherapy (P = 0.040). In contrast, none of the clinical variables, such as stage of cancer, previous receipt of chemotherapy, or interest in complementary/alternative medicine showed significant association with a patient's decision to accept or refuse chemotherapy treatment. CONCLUSIONS: Chemotherapy decisions made by older adults appear to be associated with demographic and social factors rather than with medical information. Recognizing the influence of these factors for older patients with cancer may help hematologists and oncologists to proactively address specific barriers and explore concerns regarding chemotherapy in older patients whose quality of life and longevity may be affected by treatment.

Association between Weight Change, Health Outcomes, and Mortality in Older Residents in Long-Term Care.

OBJECTIVES: Despite the numerous health risks associated with being overweight, the effect of weight loss on health and longevity remains controversial, particularly in older adults. We explored the association among weight changes, health outcomes, and mortality in older residents of a skilled nursing facility. METHODS: A 6-year retrospective chart review of residents of a long-term care facility was conducted, collecting monthly weights in addition to the clinical and demographic data of all residents for at least 1 year. Weight changes of 5% from baseline month 1 through month 12 were classified as stable, loss, or gain. Demographics, body mass index (BMI), comorbidities, number of hospitalizations, and mortality were analyzed. The association between weight change (and other demographic and clinical variables) and mortality outcomes, as well as number of hospitalizations, was assessed using the χ2 test, the Fisher exact test, Poisson regression, or negative binomial regression, as appropriate. RESULTS: A total of 116 residents fit inclusion criteria; the median age was 84 years, with 71.6% being women and 88.7% white. The median length of stay was 877.5 days. Median body weight at baseline was 137.3 lb with a BMI of 23.5. More than one-third (36.2%) of residents had stable weight, 37.9% gained weight, and 25.9% lost weight during their stay. Neither weight change category nor baseline BMI was significantly associated with mortality (P = 0.056 and P = 0.518, respectively). Multivariable models showed that receiving supplementation (P = 0.04) and having hypertension (P = 0.04) were significant predictors of mortality after adjusting for the other factors. Losing >5% body weight (compared with maintaining stable weight; P = 0.0097), being a man (P = 0.0104), receiving a supplement (P = 0.0171), and being fed by tube (P = 0.0004) were associated with an increased number of hospitalizations after covariate adjustment. CONCLUSIONS: Weight fluctuation and baseline BMI do not appear to be associated with increased risk of death in residents in a skilled nursing facility. Weight loss was associated with an increased number of hospitalizations, however.

Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors.

Medication administration errors are difficult to intercept since they occur at the end of the process. The study describes interruptions, distractions, and cognitive load experienced by registered nurses during medication administration and explores their impact on procedure failures and medication administration errors. The focus of this study was unique as it investigated how known individual and environmental factors interacted and culminated in errors.

Chest wall Ewing sarcoma: a population-based analysis.

BACKGROUND: The globally low incidence of pediatric chest wall Ewing sarcoma (CWES) has limited prior studies of this disease to mostly small, single-institution reviews. Our objective was to assess incidence, demographics, treatment patterns, and long-term survival of this disease through a population-based analysis. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results database was used to identify patients aged 0-21 y diagnosed with CWES from 1973 to 2011. Patients were grouped by decade to assess changes in treatment patterns and outcomes. The effects of clinical, demographic, and treatment variables on overall survival (OS) were assessed by the computation of Kaplan-Meier curves and the log-rank test, with Cox proportional hazard regression used for multivariable analysis. RESULTS: A total of 193 pediatric patients with histologically confirmed CWES were identified. The disease was more common in men (61%), whites (92%), and 11- to 17-y olds (49%). It was metastatic at presentation in 37% of patients. When grouped approximately by decade, 10-y OS improved progressively from 38% in 1973-1979 to 65% in 2000-2011 (P = 0.033). The use of radiation decreased from 84% in the earliest period to 40% in the most recent, whereas the proportion of patients receiving surgery increased from 75% to 85%. When controlling for covariates in multivariable analysis, male patients were found to have a higher mortality than female patients (hazard ratio: 2.4; confidence interval: 1.4, 4.4; P = 0.0028). CONCLUSIONS: This population-based analysis of CWES demonstrated an impressive trend of improving OS, with increasing use of surgery and decreasing use of radiation therapy. Our study demonstrated a gender difference in survival of CWES, with females having a better prognosis. The presence of metastatic disease is a very important prognostic factor for this illness.

Outcomes of Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgery.

OBJECTIVE: To determine in-hospital and post-discharge long-term survival in patients with prolonged intensive care unit (ICU) stays after cardiac surgery. DESIGN: Retrospective, cohort study of cardiac surgery patients from May 2007 to June 2012. SETTING: Single-center cardiac surgery ICU. PARTICIPANTS: Patients were grouped according to length of ICU stay: between 1 and 2 weeks, between 2 and 4 weeks, and>4 weeks. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 4,963 patients, 3.3%, 1.6%, and 2.9% of patients stayed 1 to 2 weeks, 2 to 4 weeks, and>4 weeks in the ICU, respectively. In-hospital mortality was 11.1%, 26.6%, and 31.0% for patients with 1 to 2 weeks, 2 to 4 weeks, and>4 weeks ICU stay, respectively. Patients with ICU stays between 1 and 2 weeks had 6 months, 1 year, and 2 year survival rates of 84.4%, 80.0%, and 75.3% after discharge, respectively. Patients with ICU stay between 2 and 4 weeks had similar 6 months, 1 year, and 2 year survival rates of 84.7%, 79.9%, and 74.1%, respectively. In contrast, patients with>4 week ICU stays had significantly lower postdischarge survival rates of 63.3%, 56.4%, and 41.1% at 6 months, 1 year, and 2 years, respectively. Postoperative stroke conferred the greatest risk of death within 1 year after discharge (odds ratio 7.6, p = 0.0140). CONCLUSIONS: In-hospital mortality rates post-cardiac surgery correlate with length of ICU stay but appear to plateau after 4 weeks. However, a>4 week ICU length of stay confers a worse long-term outcome post-hospital discharge, especially in patients with postoperative stroke.

The impact of sex, body mass index and chronic kidney disease on outcomes following percutaneous coronary intervention.

OBJECTIVE: This study sought to evaluate 1) the relationship between body mass index (BMI), chronic kidney disease (CKD) and bleeding complications in patients undergoing percutaneous coronary intervention (PCI); and 2) whether CKD modified the effect of BMI on major bleeding and major adverse cardiac and cerebrovascular events (MACCE). BACKGROUND: The interaction of CKD, sex and BMI in patients undergoing PCI is unclear. METHODS: Between 2010 and 2018, a total of 31,116 patients underwent PCI at six New York metropolitan area hospitals. Bleeding complications were classified by the Bleeding Academic Research Consortium (BARC). Major bleeding was defined as BARC≥3. MACCE was the composite of in-hospital death; myocardial infarction; cerebrovascular events and major bleeding complications. Interaction on multiplicative scales was assessed adjusting for other factors. A three-way multiplicative interaction between BMI, CKD and sex were considered and evaluated for both endpoints of primary interest (BARC≥3 and MACCE). RESULTS: Patients with BARC≥3 bleeding were older (p < 0.0001) and more likely female (p < 0.0001). A 3-way interaction existed between sex, BMI, and CKD on BARC≥3 (p = 0.02). Specifically, the effect of CKD status on odds of BARC≥3 depended on BMI group among males, whereas BMI did modify the relationship between CKD and BARC≥3 among females; after stratification by sex, a significant interaction between BMI and CKD was present in females (p = 0.03) but not in males (p = 0.43). Among females without CKD, normal BMI patients had the greatest odds of BARC≥3 compared to obese or overweight females. Contrasted to females without CKD, among females with CKD there was no significant increased odds of BARC≥3 in normal BMI patients compared to obese or overweight females. However, overweight females with CKD had a significantly increased odds of BARC≥3 compared to obese females with CKD. Furthermore, obese females with CKD had significantly greater BARC≥3 odds compared to obese females without CKD. Similarly, overweight females with CKD had an increased odds of BARC≥3 compared to overweight females without CKD. No significant interactions were found for the odds of MACCE. CONCLUSION: In patients undergoing PCI, there was evidence of a significant and complex 3-way interaction between BMI, CKD and sex for major bleeding events. The predicted probability of major bleeding was greater for females than for male patients, and for both sexes, greater among those with CKD, but BMI group influences these probabilities. Obese females with kidney disease had the lowest incidence of bleeding complications when compared with overweight or normal weight female patients undergoing PCI. This interaction was not seen in the male group or for MACCE. Furthermore, age, cardiogenic shock, STEMI and use of IABP/Impella were each independently associated with odds of major bleeding (among both males and females) and MACCE.