Neonatal abstinence syndrome: evaluating the effectiveness of an evidence-based multidisciplinary care approach.

An evidence-based, multidisciplinary neonatal abstinence syndrome protocol was developed using a stepwise continuous quality improvement (CQI) approach with the goal of standardizing care procedures for these infants. A retrospective secondary data analysis was performed to evaluate the differential effects of each step of the CQI project on 4 key clinical outcome measures: length of stay (total and post-opioid wean), weaning time from opioids, and use of adjunct medications. Data were analyzed from 386 newborn infants with a diagnosis of neonatal abstinence syndrome undergoing treatment in a level III neonatal intensive care unit. After implementation of a pharmacologic weaning protocol as a foundational first step of the CQI project, the weaning time from opioids remained stable throughout each of the subsequent CQI steps (P = .905). The overall total neonatal intensive care unit length of stay was reduced by 10.35 days (P = .002), and the length of neonatal intensive care unit stay after completing wean from opioids was reduced by 2.79 days (P < .001). Use of adjunct medications also decreased from 30.1% of infants at the initiation of the CQI project to 24.5% at the completion of the project (P = .020). These findings indicate that this multidisciplinary treatment approach led to an overall improved efficiency of both opioid weaning and symptom management for these infants.

Physician-Pharmacist Collaborative Drug Therapy Management in Pediatric Hypertension.

OBJECTIVE: Pediatric hypertension affects 2% to 5% of children and adolescents in the United States and is frequently undertreated. The increasing prevalence of pediatric hypertension and worsening physician shortage create difficulties in closing this treatment gap. Physician-pharmacist collaborations have been shown to improve patient outcomes in adult patients. Our aim was to demonstrate a similar benefit for pediatric hypertension. METHODS: Pediatric patients whose hypertension was managed at a single pediatric cardiology clinic from January 2020 to December 2021 were enrolled in collaborative drug therapy management (CDTM). Patients whose hypertension was managed in the same clinic from January 2018 to December 2019 were used as a comparison group. The primary outcomes were achievement of at-goal blood pressure at 3, 6, and 12 months and time to control of hypertension. Secondary outcomes were appointment adherence and serious adverse events. RESULTS: A total of 151 patients were included in the CDTM group, and 115 patients were included in the traditional care group. Of those, 100 CDTM patients and 78 traditional care patients were assessed for the primary outcome. Fifty-four (54%) CDTM patients and 28 (36%) traditional care patients achieved at-goal blood pressure at 12 months (OR, 2.09; 95% CI, 1.14-3.85). Appointment non-adherence was 9.4% for CDTM and 16% for traditional care (OR, 0.54; 95% CI, 0.35-0.82). Adverse events were similar between groups. CONCLUSIONS: CDTM increased rates of at-goal blood pressure without increased adverse events. Physician-pharmacist collaboration may improve treatment of hypertension in pediatric patients.

Type A Thoracic Aortic Dissection Following Endovascular Repair of a Common Iliac Artery Aneurysm.

We discuss a rare case of acute Type A thoracic aortic dissection (TAAD) following endovascular aneurysm repair (EVAR) of a common iliac artery aneurysm, which likely resulted from complications due to aberrant anatomy. Valve replacement, ascending aortic arch graft, and entry tear suture repair were necessary to contain the TAAD. Postoperative computed tomography with angiography (CTA) demonstrated stable disease, and the patient remained asymptomatic. Open and endovascular repair of the descending abdominal aorta was avoided. Few cases in the literature report TAAD following EVAR. Detection and repair of the entry site was crucial for containing the TAAD.

Treating infants with neonatal abstinence syndrome: an examination of three protocols.

OBJECTIVE: Describe the characteristics of infants with NAS and determine if treatment outcomes varied between three protocols. STUDY DESIGN: Based on medical record data, infant treatment for NAS-related withdrawal reflected one of three protocols: (1) No rescue dose (n = 836, 52.7%): Prescriber ordered initiation and escalation doses and determined when infants were eligible for weaning, (2) Rescue dose (n = 233, 14.7%): No rescue dose with the addition of a prescriber-ordered rescue dose, (3) Rescue dose by order set (n = 516, 32.6%): Rescue dose with addition of nurse-assisted order of morphine during escalation. RESULTS: The no rescue dose group had longer length of stay, days to wean, and inpatient days, and greater initial morphine dose than the two rescue dose groups (p < 0.001). Treatment outcomes between the two rescue dose protocols did not differ. CONCLUSIONS: The benefits related to rescue dosing further inform the development of a standardized NAS treatment protocol.

Pharmacomechanical Thrombolysis for Deep Vein Thrombosis in May-Thurner Syndrome.

OBJECTIVE: Patients with May-Thurner syndrome presenting with acute deep vein thrombosis benefit from early lysis of clot and endovascular treatment. We evaluated the outcome of patients with May-Thurner syndrome who presented with deep vein thrombosis, managed with pharmacomechanical thrombolysis as the primary mode of intervention, in combination with angioplasty and stent placement. METHODS: We reviewed all patients with May-Thurner syndrome managed in our institution between January 2009 to December 2015. Patency rate and postthrombotic syndrome were evaluated as primary end points. RESULTS: A total of seven patients (6 females, 1 male) with a mean ± SD age of 48 ± 17 years and mean ± SD body mass index of 29.64 ± 7.25 kg/m were identified. Six patients presented with acute deep vein thrombosis and one presented with chronic venous insufficiency. Five patients underwent pharmacomechanical thrombolysis (TRELLIS and altepase) with concomitant stenting of the common iliac vein, one had only angioplasty with stent placement, and one had only pharmacomechanical thrombolysis. Median time from presentation to pharmacomechanical thrombolysis was 4 days (range = 1-9). Patency rate and postthrombotic syndrome at 12 months were 100% and 0%, respectively. No patient experienced major bleeding or pulmonary embolism. The median length of stay was 3 days (range = 0-4). There was no mortality associated with the procedure. The mean ± SD follow-up was 26 ± 15 months. CONCLUSIONS: In patients with May-Thurner syndrome, pharmacomechanical thrombolysis is an effective approach for the management of acute deep vein thrombosis, decreasing thrombus burden, and long-term postthrombotic syndrome when used in conjunction with stenting.

Varicose veins: newer, better treatments available.

Varicose veins are not only a cosmetic annoyance: they can lead to complications that result in lost time from work and lost wages. Treatment has improved with the use of minimally invasive techniques that reduce recovery time and complications and offer better long-term results--encouraging news, considering that the problem affects 10% to 20% of adult men and 25% to 33% of adult women.

Myocardial Infarction and Left Ventricular Hypertrophy Seen on an Infant's Electrocardiogram.

The clinical and electrocardiographic features of anomalous left coronary artery from the pulmonary trunk, ALCAPA, a frequently fatal congenital cardiac malformation, are described in an 8 1/2-month-old female.

Late follow-up of nonoperative closure of secundum atrial septal defects using the King-Mills double-umbrella device.

There has been a marked increase in device closure of secundum atrial septal defects (ASDs) in the last decade. No clinical reports of late results have been forthcoming until now. The purpose of this report was to provide very long-term follow-up of nonoperative closure of secundum ADSs using the King-Mills Umbrella device. ASD closure using this technique did not appear to protect against the known secundum ASD complication of atrial arrhythmia. Twenty-seven-year follow-up of the umbrella ASD closure via the femoral vein shows effective occlusion, absence of device complications, and no reinterventions.

Effect of target biological tissue and choice of light source on penetration depth and resolution in optical coherence tomography.

The effectiveness of an optical coherence tomography (OCT) system depends largely on the light source chosen. Published data on the optical properties of tissues are used to quantify the exponential attenuation of broadband light on transport through tissue. The effective attenuation coefficient is taken to be the sum of the absorption and scattering coefficients. This is used to demonstrate the effect on the spectra of a wide range of published OCT sources and the change in system resolution induced, and hence to comment on the suitability of different sources for OCT. The tissues studied include skin dermis, liver, and gallbladder. Sources at higher wavelengths are shown to be capable of high-resolution OCT imaging at greater depths. Titanium:sapphire lasers would be most suited for high-resolution OCT over comparatively shallow depths into tissue. For lower-resolution applications of OCT, a semiconductor optical amplifier and ytterbium fiber sources have better powers and bandwidths than superluminescent diodes. The resolution of OCT systems is not reduced significantly with imaging depth.

Twenty two cases of canine neural angiostrongylosis in eastern Australia (2002-2005) and a review of the literature

Cases of canine neural angiostrongylosis (NA) with cerebrospinal fluid (CSF) evaluations in the peer-reviewed literature were tabulated. All cases were from Australia. A retrospective cohort of 59 dogs was contrasted with a series of 22 new cases where NA was diagnosed by the presence of both eosinophilic pleocytosis and anti-Angiostrongylus cantonensis immunloglobulins (IgG) in CSF, determined by ELISA or Western blot. Both cohorts were drawn from south east Queensland and Sydney. The retrospective cohort comprised mostly pups presented for hind limb weakness with hyperaesthesia, a mixture of upper motor neurone (UMN) and lower motor neurone (LMN) signs in the hind limbs and urinary incontinence. Signs were attributed to larval migration through peripheral nerves, nerve roots, spinal cord and brain associated with an ascending eosinophilic meningo-encephomyelitis. The contemporary cohort consisted of a mixture of pups, young adult and mature dogs, with a wider range of signs including (i) paraparesis/proprioceptive ataxia (ii) lumbar and tail base hyperaesthesia, (iii) multi-focal central nervous system dysfunction, or (iv) focal disease with neck pain, cranial neuropathy and altered mentation. Cases were seen throughout the year, most between April and July (inclusive). There was a preponderance of large breeds. Often littermates, or multiple animals from the same kennel, were affected simultaneously or sequentially. A presumptive diagnosis was based on consistent signs, proximity to rats, ingestion/chewing of slugs or snails and eosinophilic pleocytosis. NA was diagnosed by demonstrating anti-A. cantonensis IgG in CSF. Detecting anti-A. cantonensis IgG in serum was unhelpful because many normal dogs (20/21 pound dogs; 8/22 of a hospital population) had such antibodies, often at substantial titres. Most NA cases in the contemporary series (19/22) and many pups (16/38) in the retrospective cohort were managed successfully using high doses of prednisolone and opioids. Treatment often included antibiotics administered in case protozoan encephalomyelitis or translocated bacterial meningitis was present. Supportive measures included bladder care and physiotherapy. Several dogs were left with permanent neural deficits. Dogs are an important sentinel species for NA. Human cases and numerous cases in tawny frogmouths were reported from the same regions as affected dogs over the study period.