Relationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis.

BACKGROUND: There are very sparse data on the outcomes of children receiving prolonged extracorporeal membrane oxygenation (ECMO) after cardiac surgery. This study was aimed to evaluate the association of ECMO duration with outcomes in children undergoing surgery for congenital heart disease using the Pediatric Health Information System (PHIS) database. METHODS: Patients aged ≤18 years receiving ECMO after pediatric cardiac surgery (with or without cardiopulmonary bypass) at a PHIS-participating hospital (2004-2013) were included. De-identified data obtained from retrospective, observational dataset included demographic information, baseline characteristics, pre-ECMO risk factors, operation details, patient diagnoses, and center data. Outcomes evaluated included in-hospital mortality, length of mechanical ventilation, length of ICU stay, length of hospital stay, and hospital charges. Cox proportional hazards models were fitted to study the probability of study outcomes as a function of ECMO duration. RESULTS: Nine hundred ninety-eight patients from 37 hospitals qualified for inclusion. The median duration of ECMO run was 4 days (IQR: 1.7). After adjusting for patient and center characteristics, there was 12% increase in the odds of mortality for every 24 hours increase in ECMO duration (OR: 1.12, 95% CI: 1.07-1.18, P<0.001). Patients receiving longer duration of ECMO were associated with longer length of mechanical ventilation, longer length of ICU stay, longer length of hospital stay, and higher hospital charges. CONCLUSION: Data from this large multicenter database suggest that longer duration of ECMO support after pediatric cardiac surgery is associated with worsening outcomes.

Development and validation of the Dermatomyositis Skin Severity Index.

BACKGROUND: Dermatomyositis is an autoimmune inflammatory muscle disease with characteristic cutaneous findings of heliotrope eruption, Gottron's papules and a photodistributed eruption with poikiloderma. OBJECTIVES: To develop and validate a tool to assist with objective assessment of the skin disease of dermatomyositis. METHODS: A skin severity index was developed; content validity was evaluated by a panel of experts, and construct validity was assessed by convergence with other measures of disease severity including physician's global assessment of disease, specific skin disease changes (ulceration, poikiloderma and pruritus), and quality of life. Test and retest reliability and interobserver reproducibility were determined. RESULTS: In total, 98 subjects were enrolled. The Dermatomyositis Skin Severity Index (DSSI) showed significant correlation to the physician's global assessment, assessments of poikiloderma and self-assessment of pruritus. Inter-rater reliability showed strong correlations from 0.73 to 1. Test-retest (intrarater reliability) was completed on 33 subjects, and showed correlations above 0.75. The ability of this tool to detect clinical changes with treatment has not been fully evaluated. CONCLUSIONS: The DSSI is a valid and reliable measure of skin disease severity in dermatomyositis and can be used in future clinical trials as an assessment tool.

Better medication adherence results in greater improvement in severity of psoriasis.

BACKGROUND: Patients are commonly nonadherent to medication regimens. In dermatology, there has been little study of the effect of nonadherence on outcomes. OBJECTIVES: To test the association between adherence behaviour and changes in severity of psoriasis. METHODS: Twenty-four subjects with psoriasis were enrolled in an 8-week, left/right, controlled trial of salicylic acid plus topical tacrolimus ointment vs. salicylic acid plus placebo. Subjects were given salicylic acid to apply to all lesions. The salicylic acid was supplied in a bottle with a medication event monitoring system cap in order to assess adherence to the salicylic acid. The primary outcome for this study was the relationship between the change in the disease severity (change in sum score of erythema, scale and thickness scores for a target plaque) and medication adherence. RESULTS: The mean initial disease severity was 5.8 on a nine-point sum score scale. For the topical tacrolimus-treated side, a decrease in adherence rate of 10% was associated with a 1-point increase in severity (P < 0.05). For the placebo-treated side, adherence was not significantly correlated with changes in severity. CONCLUSIONS: Nonadherence may have a significant role in altering clinical trial data, skewing it towards ineffectiveness. Improved outcomes in psoriasis may be achievable through interventions that improve patients' adherence to treatment.

Pruritus in adult dermatomyositis.

Dermatomyositis has a significant clinical component of pruritus that has not yet been studied. Pruritus can significantly affect the life of patients. The aim of the present work was to study the degree of pruritus experienced by patients. A four-question survey was sent to patients with documented dermatomyositis. The survey used a 100-mm Visual Analogue Scale (VAS) to describe current, worst and daily pruritus, and the effect this has on daily activities. Twenty-six subjects returned completed questionnaires: four had no pruritus; the majority had a significant amount with means above 50 on the VAS. A mean of 44.6 was found for the effect on daily life. Further studies should be performed to examine the prevalence and severity of pruritus in this population and it's effect on their quality of life. Clinicians must be aware of the significant pruritus and provide adequate therapy to improve quality of life.

Timed Pediatric Risk of Mortality Scores predict outcomes in pediatric liver transplant recipients.

More reliable methods are needed to identify children at risk for poor outcomes following liver transplantation. The Pediatric Risk of Mortality (PRISM) Score is a physiology-based scoring system used to quantify risk of mortality in pediatric intensive care unit (ICU) populations. We evaluated the PRISM Score as a predictor of outcomes including survival in the pediatric liver transplant (LT) population. We retrospectively reviewed the records of 67 consecutive LTs performed between August 1997 and February 2000 at an urban, tertiary children's hospital in Chicago, IL, USA. Four PRISM Scores were calculated to determine which periods were most meaningful. A Classic PRISM Score was calculated during first 24 h of ICU admission, and three PRISM Scores were timed with the patient's transplant: a pre-LT PRISM Score (24 h prior to transplant whether in ICU or not), a 24-h post-LT PRISM Score and a 48-h post-LT PRISM Score. These PRISM Scores and other predictors including transplant number, UNOS status and PELD Score were compared with outcomes including survival using univariate methods. The pre-LT, the 24- and the 48-h PRISM Score were associated with the post-LT number of ventilated days (p < 0.05), ICU days (p < 0.05) and with 1-yr survival (p < 0.04). The PRISM Scores were not related to the post-LT hospital length of stay (LOS) or to 1-yr re-transplantation. The PELD Score correlated with the post-LT hospital LOS, but was not associated with mortality or with the ICU LOS. A patient's UNOS status and Classic PRISM Score were not associated with any of the outcomes measured. PRISM Scores are valid predictors of outcome including survival in pediatric LT recipients. These findings help to demonstrate the importance in this population of a patient's general physiologic condition and its influence on the overall hospital course and survival.

A field investigation of the effects of bovine viral diarrhea virus infection around the time of insemination on the reproductive performance of cattle.

During a study of methods of synchronizing estrus in Bos indicus cattle, blood was collected from 169 heifers and 38 cows 2 to 3 days prior to artificial insemination (AI), and then again at Day 51 and Day 210 after AI to determine the incidence of infection with bovine viral diarrhea (BVD) virus. Prior to insemination 53 and 68% of the cows and heifers, respectively, were seronegative to the BVD virus. At Day 51 after AI, 70 and 32% of the seronegative cows and heifers, respectively, had seroconverted; but between Day 51 and Day 210, only 17 and 3% of the seronegative cows and heifers, respectively, had seroconverted. The Day- 51 pregnancy rate of cows which were immune (seropositive) to BVD virus infection at the time of AI was similar to the rate of the cows which became infected around the time of AI. However, the pregnancy rate of the immune heifers (44%, n=54) was significantly (P=0.04) greater than the rate of the heifers which became infected around the time of AI (24%, n=37). It was concluded that infection of susceptible females with BVD virus around the time of AI may significantly lower the pregnancy rate.

Evaluation of three estrus synchronization regimens for use in extensively managed Bos indicus and Bos indicus/taurus heifers in Northern Australia.

Two herds of extensively managed yearling Bos indicus and Bos indicus x Bos taurus heifers (n=169) were assigned to one of three estrus synchronization treatment groups. The treatments consisted of 1) two injections of the prostaglandin (F2alpha) analogue, luprostiol (7.5 mg), given 12-d apart; 2) insertion of an intravaginal progesterone-releasing device (CIDR-B), followed by 400 IU i.m. pregnant mare serum gonadotrophin (PMSG) and 7.5 mg luprostinol at CIDR-B removal or 3) subcutaneous progestagen implant (SMB) for 10-d, followed by 400 IU i.m. and 7.5 mg i.m. luprostiol at implant removal. A dual tail paint-raddle system was used to evaluate response to treatment. Each treatment group was inseminated according to the manufacturer's recommendations for fixed-time artificial insemination (A.I.; luprostiol, 72 h after the second injection, SMB and CIDR-B 48h after implant/device removal). The overall 51-d pregnancy rates for the three treatments were 18.6% (luprostiol), 48.8% (CIDR-B), and 53.3% (SMB). There were significant differences in the pregnancy rate between CIDR-B and luprostiol (P=0.004) and between SMB and luprostiol (P=or<0.0001), but there was no difference in pregnancy rate between CIDR-B and SMB treatment.

Body condition scoring and weight estimation of horses.

Three hundred and seventy two horses of varying breeds, height and fatness were weighed and measured for height at the withers. They were assessed for condition score by adaptation of a previously published method. The heart girth and length of 281 of the horses were also measured. Weight of horses was highly correlated (P less than 0.001) with height (r2 = 0.62), condition score (r2 = 0.22) and girth2 x length (r2 = 0.90). Nomograms were constructed to predict weight from height and condition score, and girth and length measurements. Weight can also be accurately estimated from the formula: (formula, see text) The average value of 'Y' in this experiment was 11900 and this estimated weight with more accuracy than some previously published values of 'Y'. Racing Thoroughbred horses were found to be significantly lighter than non-racing Thoroughbreds of the same height and condition score. The method of assessment of condition score was shown to be repeatable between different operators with varying degrees of experience.

Haemorrhagic necrotising enteritis in foals associated with Clostridium perfringens.

Two foals aged 35 and 48 h from 2 Thoroughbred studs died several hours after developing clinical signs of depression, severe haemorrhagic diarrhoea and dehydration. Both foals had an acute haemorrhagic enteritis extending from the anterior jejunum to the terminal ileum which was characterised histologically by villus necrosis. Necrotic villi were surrounded by large numbers of rod-shaped Gram positive bacteria. Clostridium perfringens was recovered from the intestines of both foals and the isolates were considered to be C. perfringens type C. Other cases of diarrhoea were also observed in foals of the same age on these 2 studs, but the aetiology of these was not determined.

Fifteen-year experience with screening for phenylketonuria with an automated fluorometric method.

An automated fluorometric method, rather than the Guthrie test, has been used in North Carolina for neonatal screening for phenylketonuria (PKU). Although there is no testing law, 97% of newborn infants are screened. Twelve children with PkU, not referred for dietary management, were born before the screening program was established, were born elsewhere, or were successfully identified at birth but not referred for treatment. None was missed because of laboratory error or because of the lack of a testing law. Positive skewing was noted among initial blood phenylalanine levels of 49 infants with PKU and severe hyperphenylalaninemia. Log transformations caused the values to be normally distributed and permitted the calculation of tolerance and confidence limits. These provided estimates of the percentage of phenylketonuric infants whose initial blood levels might fall below any given cutoff value.

Hypertension control in a rural biracial community: successes and failures of primary care.

Through a total community survey and a medical record review, we examined hypertension awareness, treatment, and control in a biracial rural community rich in primary care resources. The overall prevalence of hypertension among the 2,939 respondents was 20.5 per cent; 82 per cent of hypertensives were aware of their condition; 68 per cent were on treatment; and 55 per cent were under control. Comparison of data sources revealed discrepancies and misconceptions about diagnosis and treatment. Nearly one-third of the population reported a history of hypertension despite the fact that most of them were untreated and were normotensive. Conversely, one-third of "undetected" hypertensives had notation of the diagnosis in their medical records. Discontinuation of treatment accounted for over one-half of aware but untreated hypertension. Misconceptions about therapy contributed to failures of control in the treated group. These findings suggest that difficulties in the transmission of information about hypertension contribute importantly to failures of control.