Prediction of short- and long-term outcomes using pre-operative ventricular size in infants with post-hemorrhagic ventricular dilation.

PURPOSE: Post-hemorrhagic ventricular dilation (PHVD) leads to developmental delays in premature infants, yet the optimal timing of neurosurgical interventions is unknown. Neuroimaging modalities have emerged to delineate injury and follow the progression of PHVD. Fronto-temporal horn ratio (FTHR) is used as a marker of ventricular dilation and can be a standardized tool to direct the timing of neurosurgical intervention. Our study determined a pre-operative FTHR measurement threshold to predict short- and long-term outcomes. METHODS: This is a retrospective cohort study of premature infants with severe intraventricular hemorrhage (IVH) who developed PHVD requiring neurosurgical intervention and were treated in a level IV NICU between 2012 and 2019. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were performed to evaluate the accuracy of pre-operative FTHR for predicting developmental delay. In-hospital outcomes and developmental assessments were analyzed. RESULTS: We reviewed 121 charts of infants with IVH and identified 43 infants with PHVD who required neurosurgical intervention. We found FTHR measurements were an excellent predictor of cognitive and motor delay with an AUC of 0.89 and 0.88, respectively. An average pre-operative FTHR of ≥ 0.67 was also associated with worse lung and feeding outcomes. There was excellent inter-observer reliability of individual components of FTHR measurements. CONCLUSIONS: Early intervention for PHVD is ideal but not always practical. Identification of ventricular size thresholds associated with better outcomes is needed to direct timing of neurosurgical intervention.

Trends in the early care of infants with myelomeningocele in the United States 2012-2018.

PURPOSE: The early care of children with spina bifida has changed with the increasing availability of fetal surgery and evidence that fetal repair improves the long-term outcomes of children with myelomeningocele. We sought to determine current trends in the prevalence and early care of children with myelomeningocele using a national administrative database. METHODS: This is a retrospective, cross-sectional cohort study of infants with spina bifida admitted within the first 28 days of life using the 2012-2018 Healthcare Cost and Utilization Project National Inpatient Database. Patients with spina bifida were identified by ICD code and stratified into a cohort with a coded neonatal repair of the defect and those without a coded repair. This database had no identifier specific for fetal surgery, but it is likely that a substantial number of infants without a coded repair had fetal surgery. RESULTS: We identified 5,090 patients with a coded repair and 5,715 without a coded repair. The overall prevalence of spina bifida was 3.94 per 10,000 live births. The percentage of patients without neonatal repair increased during the study period compared to those with repair (p = 0.0002). The cohort without neonatal repair had a higher risk of death (p < 0.001), prematurity (p < 0.001), and low birth weight (p < 0.001). More shunts were placed in patients who underwent neonatal repair (p < 0.001). Patients without neonatal repair were less likely to have public insurance (p = 0.0052) and more likely to reside in zip codes within the highest income quartile (p = 0.0002). CONCLUSIONS: The prevalence of spina bifida from 2012 to 2018 was 3.94 per 10,000 live births, with an increasing number of patients without neonatal repair of the defect, suggesting increased utilization of fetal surgery. Patients without neonatal repair had a higher risk of death, prematurity, and low birth weight but were more likely to have commercial insurance and reside in high-income zip codes.

HOPE and DREAM: A Two-Clinic NICU Follow-up Model.

OBJECTIVE: The natural extension of inpatient-focused neonatal neurocritical care (NNCC) programs is the evaluation of long-term neurodevelopmental outcomes in the same patient population. CLINICAL DESIGN: A dedicated and collaborative team of neonatologists, neonatal neurologists, neuropsychologists, neurosurgeons, physical medicine and rehabilitation physicians, and psychologists are necessary to provide personalized medicine, developmental assessments, and parental education for NNCC graduates. To achieve this goal, we devised a two-clinic follow-up model at Children's Wisconsin: HOPE (Healthy Outcomes Post-ICU Engagement) and DREAM: Developmentally Ready: Engagement for Achievement of Milestones) clinics. Those infants with significant neurologic diagnoses attend DREAM clinic, while all other high-risk neonatal intensive care unit (NICU) infants are seen in the HOPE clinic. CONCLUSION: These clinic models allow for a targeted approach to post-NICU care, which has improved family engagement and perceptions of value. KEY POINTS: · Infants with neurologic compromise are a specialized population with increasing survival.. · Interdisciplinary NICU follow-up brings together previously separated outpatient service lines.. · Our novel clinic model allows for specialized developmental assessments..

Symptomatic Dermal Inclusion Cysts in Infants following Fetal Surgery for Myelomeningocele: Report of Two Cases and Review of the Literature.

INTRODUCTION: It remains unclear if fetal repair of myelomeningocele (MM) is associated with a greater risk of developing symptomatic dermal inclusion cysts (ICs) at the neural placode. We report two infants treated with fetal surgery who developed symptomatic IC at less than 1 year of age, and we discuss the current literature on symptomatic IC in children with MM. CASE PRESENTATION: Two infants underwent fetal MM repair at 24 weeks of gestational age. Case 1 was born at 30 weeks and had two revisions of the MM wound early in life. At 8 months of age, the patient presented with meningismus and imaging findings of an IC, which was resected at the time of presentation. At 3 years of age, this patient was found to have recurrence of the IC after presenting with worsening bladder function and underwent repeat debulking with no recurrence at 6 years of age. Case 2 was born at 32 weeks of gestational age with uncomplicated recovery. At 8 months of age, the patient presented with irritability and fullness at the lumbar repair site. Imaging showed a large IC with restricted diffusion and extension into the subcutaneous tissue; this was resected completely at the time of presentation, see intraoperative photographs. There has been no sign of recurrence at age of 15 months. CONCLUSIONS: Careful monitoring for IC in infancy in MM patients who have had fetal surgery is recommended.

Thiazide-Associated Hyponatremia: Clinical Manifestations and Pathophysiology.

Hyponatremia can complicate thiazide use in a minority of susceptible individuals and can result in significant morbidity and even mortality. Risk factors for thiazide-associated hyponatremia include age, female sex, and possibly low body mass. A genetic susceptibility has recently been uncovered. Although frequently developing early after thiazide treatment initiation, many cases of hyponatremia present after months or years of use. Many cases are asymptomatic or have mild symptoms, but seizures and/or coma may develop, especially in those with acute onset. The pathophysiology is incompletely understood and includes some combination of excessive fluid intake, cation (sodium and potassium) depletion, osmotic inactivation of sodium, and reduced ability to excrete free water. Reduced distal delivery of filtrate, reduced solute load (urea), direct inhibition of the sodium-chloride cotransporter, and increased collecting duct permeability to water mediated by some combination of antidiuretic hormone, prostaglandins, and thiazides themselves may contribute to this diluting defect. The predominant pathophysiologic mechanism(s) varies from patient to patient. The cornerstone of therapy is cessation of thiazide use, cation repletion, and oral fluid restriction. If severely symptomatic, 3% saline solution may be indicated. Overly rapid correction of chronic hyponatremia must be avoided in all cases.

Left atrial appendage occlusion: a critical appraisal updated with recent evidence.

PURPOSE OF REVIEW: To allow readers to fully appreciate the uncertainties with this novel yet invasive approach to stroke prevention. RECENT FINDINGS: Percutaneous left atrial (LA) appendage occlusion has emerged as potential nonpharmacologic means to prevent stroke and systemic embolism in patients with atrial fibrillation. Yet the evidence underpinning this new technology is not definitive. SUMMARY: In this review, we consider the internal and external validity of the regulatory trials, pathophysiologic basis for LA appendage occlusion and clinical tradeoffs of the procedure.

Diffuse Midline Glioma With Osseous Metastases at Diagnosis: A Case Report.

Extraneural metastasis is extremely rare in pediatric patients with high-grade glioma and carries a grim prognosis. Detection of metastases at initial presentation is even rarer. A 15-year-old adolescent girl presented with paraplegia, urinary retention, and a constellation of systemic symptoms. Imaging showed a fourth ventricular lesion, innumerable intradural lesions, leptomeningeal seeding throughout the neuraxis, and numerous osteoblastic lesions involving the spine, ribs, sternum, pelvis, humerus, and femurs. Pathology confirmed metastatic diffuse midline glioma, H3K27M-mutant. Our patient died 2 weeks after initial presentation. Further work is needed to develop effective treatment strategies for these high-risk patients.

Industry Payments to US Physicians by Specialty and Product Type.

This study examines the distribution of payments within and across specialties and the medical products associated with the largest total payments.

Survival Outcomes Following the Use of Extracorporeal Membrane Oxygenation as a Rescue Technology in Critically Ill Patients: Results From Pennsylvania 2007-2015.

OBJECTIVE: To examine real-world outcomes of survival, length of stay, and discharge destination, among all adult extracorporeal membrane oxygenation admissions in one state over nearly a decade. DESIGN: Retrospective analysis of administrative discharge data. SETTING: State-wide administrative discharge data from Pennsylvania between 2007 and 2015. PATIENTS: All 2,948 consecutive patients billed under a Diagnosis-Related Grouper 3 grouper and in whom a procedural code for extracorporeal membrane oxygenation was present, admitted between the beginning of 2007 and the end of 2015 to hospitals regulated by the state of Pennsylvania. Admitting diagnoses were coded as respiratory, cardiac, cardiac arrest, or uncategorized based on administrative data. MEASUREMENTS AND MAIN RESULTS: Unadjusted in-hospital mortality, length of stay, and discharge destination. Summary statistics and tests of differences by age 65 years or older and by admitting diagnosis were performed. Outcomes by age were plotted using running-mean smoothed graphs. Over the 9-year period, the average observed death rate was 51.7%. Among all survivors, 14.6% went home to self-care and a further 15.2% to home health care. Of all survivors, 43.8% were readmitted within 1 month, and 60.6% within 1 year. Among elderly survivors, readmission rates were 52.3% and 65.5% within 1 month and 1 year, respectively. The likelihood of dying in-hospital increased with age that of being discharged home or to postacute care decreased. CONCLUSIONS: In a "usual clinical practice" setting, short-term outcomes are similar to those observed in clinical trials such as Conventional Ventilation or ECMO for Severe Adult Respiratory Failure, in registries such as extracorporeal life support organization, and in smaller single-site studies. More data on longer term follow-up are needed to allow clinicians to better inform patient selection and care.

Predicting Survival in Patients Treated With Extracorporeal Membrane Oxygenation After Myocardial Infarction.

OBJECTIVES: Acute myocardial infarction is the most common cause of cardiogenic shock. Although the number of patients with acute myocardial infarction complicated by cardiogenic shock who were treated with venoarterial extracorporeal membrane oxygenation increased during the last decade, detailed data on survival are lacking. We sought to analyze covariates that were independently associated with survival in this patient population and to externally validate the newly developed prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by venoarterial Extracorporeal membrane oxygenation (ENCOURAGE) score. DESIGN: Retrospective clinical study. SETTING: A single academic teaching hospital. PATIENTS: Adult patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation from June 2008 to September 2016. INTERVENTIONS: Fourteen individual variables were assessed for their association with the primary endpoint. These variables were prespecified by the study team as being the most likely to affect survival. A receiver operating characteristic analysis was also performed to test the ability of the ENCOURAGE score to predict survival in this patient cohort. MEASUREMENTS AND MAIN RESULTS: The primary endpoint of the study was in-hospital survival. A total of 61 patients were included in the analysis. Thirty-seven (60.7%) could be weaned from venoarterial extracorporeal membrane oxygenation and 36 (59.0%) survived. Survival was significantly higher in patients less than 65 years old (odds ratio, 14.6 [CI, 2.5-84.0]; p = 0.003), whose body mass index was less than 32 kg/m (odds ratio, 5.5 [CI, 1.2-25.4]; p = 0.029) and international normalized ratio was less than 2 (odds ratio, 7.3 [CI, 1.3-40.1]; p = 0.022). In patients where the first lactate drawn was less than 3 mmol/L, the survival was not significantly higher (odds ratio, 4.4 [CI, 0.6-32.6]; p = 0.147). The C-statistic for predicting survival using a modified version of the ENCOURAGE score, which replaced prothrombin activity less than 50% with an international normalized ratio greater than 2, was 0.74 (95% CI, 0.61-0.87). CONCLUSIONS: In this single-center study, several important covariates were associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation and the ENCOURAGE score was found to be externally valid for predicting survival to hospital discharge.

Fluoroscopy pulse rate reduction during diagnostic and therapeutic imaging in the cardiac catheterization laboratory: An evaluation of radiation dose, procedure complications and outcomes.

OBJECTIVES: To evaluate radiation reduction by reducing fluoroscopy pulse rate in diagnostic cardiac catheterizations and percutaneous coronary interventions (PCI) as well as outcomes at 30 days and six months. BACKGROUND: Radiation exposure to the public at large has increased dramatically over the past three decades, and the cardiac catheterization laboratory is a large contributor. Fluoroscopy pulse rate is one way to decrease radiation exposure. METHODS: Fluoroscopy pulse rate was reduced from 10 pulses/sec (p/s) to 7.5 p/s as part of an internal quality improvement project. A retrospective analysis of all cardiac catheterizations was performed, evaluating Air KERMA at the interventional reference point (Ka, r ), Air KERMA area product (PKA ), procedural complications and major adverse cardiac events at 30 days and 6 months. RESULTS: In diagnostic catheterization median PKA (µGy·m2 ) and Ka,r (mGy) were significantly reduced (PKA - 5,613.3 vs. 4,400, P < 0.001; Ka,r - 703.0 vs. 621.0, P = 0.041). In PCI, median PKA and Ka,r were further reduced (PKA - 13,481.6 vs. 10,648.0, P < 0.001; Ka,r - 1787.0 vs. 1,459.0, P = 0.002). There was no difference in complications, fluoroscopy time or number of stents placed. There was no difference in MACE after adjustment for number of STEMIs. CONCLUSIONS: Reducing fluoroscopy pulse rates to 7.5 from 10 is an effective way to reduce patient radiation exposure across meaningful dose indices. A pulse rate of 7.5 p/s is safe, with no difference in complications or outcomes. A fluoroscopy pulse rate of 7.5 p/s should be given strong consideration for a new standard. © 2016 Wiley Periodicals, Inc.

Evaluating the older adult experience of a web-based, tablet-delivered heart failure self-care program using gerontechnology principles.

The goals of gerontechnology are to develop technology that facilitates goal attainment and improves satisfaction with life for older adults. Few mHealth technology systems have been evaluated using these criteria. The purpose of this paper was to present the qualitative analysis of participant post-intervention interviews from the tablet-delivered Penn State Heart Assistant intervention. Semi-structured interviews (n = 12) were conducted after the completion of a 30 day study protocol. Interviews were transcribed verbatim by a professional transcriptionist, then analyzed using an iterative process of coding, categorization, and thematic development using DeDoose software and a gerontechnology interpretive lens. Two themes with six subthemes arose: Benefits - information sharing with others, usability and learnability, use of help resources; Suggestions - continuing use after the study, technical problems, participant suggested improvements. Interviews suggested improved goal attainment and satisfaction with life for the older adults with use of the tablet.

Positive predictive value of an elevated cardiac troponin for type I myocardial infarction in ED patients based on the chief complaint.

BACKGROUND: Cardiac troponin testing is used to aid the diagnosis of myocardial infarction (MI) in the emergency department (ED) for patients who present with a range of symptoms. From a clinical perspective, the distinction between MI due to acute coronary artery thrombosis (type I MI) and other forms of direct and secondary myocardial injury (type II MI) is very important. However, the positive predictive value (PPV) of an elevated troponin for diagnosing type I MI, based on clinical history, has not been described. The objective of this study was to determine the PPV of an elevated troponin for type I MI based on the ED chief complaint. METHODS: We retrospectively reviewed the medical records of 1772 consecutive patients who had a troponin ordered in the ED at a tertiary care center over the period of March 1, 2013, to April 30, 2013. The chief complaint was based on official ED coding. For patients with a positive troponin, 2 authors independently reviewed the electronic medical record pertaining to the index encounter and subsequent hospitalization to adjudicate the cause. RESULTS: There was a significant association between the PPV of an elevated troponin for type I MI and the chief complaint. Patients with a chief complaint of chest pain were significantly more likely to have a type I MI compared to those without (PPV 84% vs 20%; Adjusted Odds Ratio (AOR), 14.31; P < .0001). There was also a significant association between the rate of type I MI and the chief complaint in all patients who had a troponin drawn. Patients with a chief complaint of chest pain were significantly more likely to have a type I MI compared to those without (PPV 9.8% vs 1.3%; AOR, 7.34; P < .0001). CONCLUSION: Applying information on the PPV of troponin for type I MI based on the clinical history could improve troponin utilization and clinical decision making.

Insertion of the Avalon cannula for venovenous extracorporeal membrane oxygenation in a patient with an implanted ASD occlusion device.

Use of the Avalon Elite bicaval dual lumen catheter (Maquet Cardiopulmonary AG, Rastatt, Germany) can be effective in patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO) for adult respiratory distress syndrome (ARDS). Proper placement of the cannula is important in providing adequate therapy and avoiding life-threatening complications.  We report a case of successful cannulation in a patient with an implanted atrial septal defect (ASD) occlusion device who developed severe refractory ARDS.

Relationships Between Personality Traits and Perceived Stress in Surrogate Decision-Makers of Intensive Care Unit Patients.

INTRODUCTION: Personality traits, specifically neuroticism, are related to stress in surrogate decision-makers (SDMs) in outpatient settings. We hypothesized that intrinsic traits are related to SDM stress in the intensive care unit (ICU) to determine if personality considerations should be included in interventions to support SDMs. METHODS: Eligible participants (adult SDMs of non-capacitated ICU patients) completed validated questionnaires including stress (Impact of Events Scale-Revised, IES-R) and personality (Big Five Inventory, BFI) within 72 hours of ICU admission and again at 3 months post-ICU discharge (in addition to a qualitative interview). Bivariate Pearson correlations explored the relationship between BFI and IES-R at each time point (95% CI) and t-tests explored the relationship between stress and COVID-19. Mixed-methods analysis integrated qualitative and quantitative data. RESULTS: Of 32 SDMs, 71.9% were female, 93.8% white, and 97.0% were family members. Neuroticism was not significantly correlated to IES-R at 72 hours (r = 0.09; p = 0.64), but r increased 3 months post-discharge (r = 0.32; p = 0.07). Other BFI traits did not show similar patterns. Total stress was greater in surrogates of COVID-19-positive patients (COVID-19-positive: 60.6; COVID-19-negative: 49.8; p = 0.025). Mixed-methods analysis demonstrated that participants with high neuroticism scores had poorer emotional regulation than those with low neuroticism scores. CONCLUSIONS: This study supports that personality, particularly neuroticism, influences the stress of SDMs in the ICU. Further study of personality traits may identify surrogates who are at higher risk of stress-related disorders, which can guide future interventions.

Controversies in Hypertension V: Resistant and Refractory Hypertension.

Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-ß blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.

Obese patients with new onset atrial fibrillation/flutter have higher risk of hospitalization, cardioversions, and ablations.

Obesity significantly increases the risk of developing atrial fibrillation (AF) and atrial flutter (AFL) and evidence from randomized trials indicates that weight loss may reduce the burden of AF/AFL in obese patients; however, the relationship between obesity and healthcare resource utilization in AF/AFL patients is lacking. We sought to assess this relationship in patients with newly diagnosed AF/AFL in a nationally representative cohort of the United States by using the MarketScan® claims database. International Classification of Diseases, Tenth Revision [ICD 10] diagnosis codes were used to select individuals with a new diagnosis of AF/AFL in 2017 and 2018, adjudicate baseline variables and to classify them according to obesity status. Patients were followed for two years at which point all data was censored. The primary outcome of the study was hospitalizations due to AF/AFL. Cox proportional hazards regression models were used to assess the adjusted hazard ratio for obese versus non-obese patients. There were 55,271 patients with new onset AF/AFL, which included 43,314 (78.4 %) who were non-obese and 11,957 (21.6 %) who were obese. There were significantly more males than females among non-obese (65.3 % vs. 34.7 %) and obese individuals (62.3 % vs. 37.7 %). The average age (SD) was similar in the non-obese (54.5 (9.7)) and obese cohorts (54.7 (8.4)), respectively. The incidence of Emergency Department visits (4.0 % vs. 6.5 %), hospitalizations (5.5 % vs. 10.7 %), cardioversions (6.6 % vs. 12.7 %), and ablation procedures (5.3 % vs. 8.6 %) were significantly increased among obese patients.

What Counts as a Surrogate Decision?

When patients lose decision-making capacity, others must make surrogate decisions on their behalf. What counts as a surrogate decision might seem self-evident. But as clinician-researchers in the field of advance care planning, we have found that it is not always so clear-cut. In this paper, we describe how and why this is a matter of concern, a novel approach for assessing whether a surrogate decision occurred, and findings from this assessment.