Aortic stiffness and left ventricular diastolic function in children with well-functioning bicuspid aortic valves.

AIMS: Aortic stiffness and diastolic function are abnormal in adults with bicuspid aortic valves (BAVs). The goal of this study was to determine the relationship between aortic stiffness and left ventricular (LV) diastolic impairment in children with well-functioning BAV and no associated congenital heart disease. METHODS AND RESULTS: This is a retrospective review of echocardiograms in children with isolated BAV (group BAV; N = 50) and healthy frequency-matched controls (group Control; N = 50). We analysed LV systolic and diastolic function, proximal and distal ascending aortic stiffness index (SI), distensibility, and strain. Age range was 0.2-20 (median 11) years. There was no significant difference in blood pressure, normalized LV size and systolic function between the groups. Several parameters of LV diastolic function were lower in group BAV compared with group Control (e.g. septal E': BAV 12 ± 2.3 cm/s; Control 13.5 ± 1.8 cm/s, P < 0.001). All parameters of proximal and distal ascending aortic elasticity were abnormal in group BAV vs. Control (SI proximal ascending aorta: BAV 4.2 ± 1.6; Control 3.0 ± 0.9, P < 0.001). There was no significant correlation between parameters of aortic elasticity and diastolic function. In a subgroup analysis of children with fusion of the right-non vs. right-left coronary cusps, there was no significant difference for any of the parameters analysed. CONCLUSION: Even children with well-functioning isolated BAV have abnormalities in aortic elasticity and diastolic function when compared with the Control group. However, a relationship between the two could not be established.

Neutrophil CD64 with hematologic criteria for diagnosis of neonatal sepsis.

OBJECTIVE: To assess the sensitivity and specificity of neutrophil CD64 as a diagnostic marker for clinical sepsis (based on a hematologic score) and as an additional marker with hematologic parameters for culture-proven sepsis in neonates. STUDY DESIGN: Prospective observational cohort over 18 months in a single-center neonatal intensive care unit. RESULTS: Hematologic and CD64 data were available on 1,156 sepsis evaluations done in 684 infants, of which 411 (36%) instances of positive clinical sepsis were identified. The CD64 index for clinical sepsis had an overall area under the receiver operating characteristic curve of 0.71. An optimum CD64 cut point value of 2.19 for late-onset clinical sepsis was calculated with a sensitivity of 78%, a specificity of 59%, and a negative predictive value of 81%. The birth weight-specific CD64 cut point for early onset clinical sepsis was 3.13, 2.34, and 2.05 for very low, low, and normal birth weight, respectively. Neutrophil CD64, in combination with the absolute neutrophil count or the absolute band count, had the highest sensitivity (91%) and specificity (93%), respectively, to diagnose culture-proven sepsis. CONCLUSION: We conclude that neutrophil CD64 index can be incorporated with specific hematologic criteria as an additional marker for diagnosis of neonatal sepsis.

Aortic stiffness and left ventricular diastolic function in children following early repair of aortic coarctation.

Aortic stiffness and diastolic function are abnormal in adults with repaired coarctation of the aorta (CoA). The goal of this study was to determine the relation between aortic stiffness and left ventricular (LV) diastolic impairment in children who had undergone CoA repair very early in life. This is a retrospective review of echocardiograms in children with isolated repaired CoA (group CoA; n = 24) and healthy matched controls (group Normal; n = 24). We analyzed systolic and LV diastolic functions, proximal and distal ascending aortic stiffness indices (SIs), distensibility, and strain. Age range was 0.3 to 21 (median 9) years. Age at time of CoA repair was 0 to 24 (median 0.5) months. Median time since CoA repair was 6 years. There was no significant difference in blood pressure, LV size, and systolic function between the groups. LV diastolic function was impaired in group CoA compared with group Normal (septal E': CoA 10.3 ± 1.6 cm/s and Normal 13.4 ± 1.9 cm/s, p <0.001). All parameters of proximal and distal ascending aortic elasticities were abnormal in group CoA versus Normal (SI of proximal ascending aorta: CoA 4.9 ± 1.6 and Normal 2.7 ± 0.6, p <0.001). Across all patients, there was a strong correlation between septal E' and proximal ascending aortic SI (r = -0.72, p <0.001). In conclusion, even children who underwent CoA repair at a very young age have abnormal LV diastolic function and aortic elasticity compared with controls and there is a linear relation between the 2. LV diastolic dysfunction in patients with repaired CoA may be due to chronically increased afterload.

Natural ventilation reduces high TB transmission risk in traditional homes in rural KwaZulu-Natal, South Africa.

BACKGROUND: Transmission of drug susceptible and drug resistant TB occurs in health care facilities, and community and households settings, particularly in highly prevalent TB and HIV areas. There is a paucity of data regarding factors that may affect TB transmission risk in household settings. We evaluated air exchange and the impact of natural ventilation on estimated TB transmission risk in traditional Zulu homes in rural South Africa. METHODS: We utilized a carbon dioxide decay technique to measure ventilation in air changes per hour (ACH). We evaluated predominant home types to determine factors affecting ACH and used the Wells-Riley equation to estimate TB transmission risk. RESULTS: Two hundred eighteen ventilation measurements were taken in 24 traditional homes. All had low ventilation at baseline when windows were closed (mean ACH = 3, SD = 3.0), with estimated TB transmission risk of 55.4% over a ten hour period of exposure to an infectious TB patient. There was significant improvement with opening windows and door, reaching a mean ACH of 20 (SD = 13.1, p < 0.0001) resulting in significant decrease in estimated TB transmission risk to 9.6% (p < 0.0001). Multivariate analysis identified factors predicting ACH, including ventilation conditions (windows/doors open) and window to volume ratio. Expanding ventilation increased the odds of achieving ≥12 ACH by 60-fold. CONCLUSIONS: There is high estimated risk of TB transmission in traditional homes of infectious TB patients in rural South Africa. Improving natural ventilation may decrease household TB transmission risk and, combined with other strategies, may enhance TB control efforts.

Performance of Clinical Criteria for Screening of Possible Antiretroviral Related Mitochondrial Toxicity in HIV-Infected Children in Accra.

Mitochondrial damage is implicated in highly active antiretroviral therapy (HAART) toxicity. HIV infection also causes mitochondrial toxicity (MT). Differentiating between the two is critical for HIV management. Our objective was to test the utility of the Mitochondrial Disease Criteria (MDC) and the Enquête Périnatale Française (EPF) to screen for possible HAART related MT in HIV-infected children in Ghana. The EPF and MDC are compilations of clinical symptoms, or criteria, of MT: a (+) score indicates possible MT. We applied these criteria retrospectively to 403 charts of HIV-infected children. Of those studied, 331/403 received HAART. Comparing HAART exposed and HAART naïve children, the difference in EPF score, but not MDC, approached significance (P = 0.1). Young age at HIV diagnosis or at HAART initiation was associated with (+) EPF (P ≤ 0.01). Adherence to HAART trended toward an association with (+) EPF (P = 0.09). Exposure to nevirapine, abacavir, or didanosine increased risk of (+) EPF (OR = 3.55 (CI = 1.99-6.33), 4.76 (2.39-9.43), 4.93 (1.29-18.87)). Neither EPF nor MDC identified a significant difference between HAART exposed or naïve children regarding possible MT. However, as indicators of HAART exposure are associated with (+) EPF, it may be a candidate for prospective study of possible HAART related MT in resource-poor settings.

Markers of maternal depressive symptoms in an urban pediatric clinic.

OBJECTIVE: To identify markers of maternal depressive symptoms in medical records of children aged 1-6 years. STUDY DESIGN: Using a case-control methodology, mothers who were screened for depressive symptoms with the Quick Inventory of Depressive Symptomatology Self-Rated Questionnaire (QIDS-SR) at well-child visits between June 2006 and June 2008 in an inner-city pediatric clinic were grouped into cases with depressive symptoms (QIDS-SR score ≥ 11) and controls with no symptoms (QIDS-SR score ≤ 5). Potential markers for maternal depressive symptoms were collected from the children's medical record and grouped into 3 domains: (1) child health and development (eg, maternal concerns/negative attributions regarding the child's behavior); (2) child health care utilization (eg, missed appointments); and (3) maternal psychosocial factors (eg, single parent). The association between maternal depressive symptoms and each factor was determined using multiple logistic regression to calculate aORs. RESULTS: Maternal depressive symptoms were significantly associated with reports of concerns/negative attributions about the child's behavior (aOR, 2.35; P = .01) and concerns about speech (aOR, 2.40; P = .04) and sleep (aOR, 7.75; P < .001); these were identified at the visit when the depression screening was done. Other associations included history of maternal depression (aOR, 4.94; P = .001) and a previous social work referral (aOR, 1.98; P = .01). CONCLUSION: Information readily available to pediatricians was associated with maternal depressive symptoms and can serve as clinical markers to help identify at-risk mothers during well-child visits.

Incidence and acute complications of asymptomatic central venous catheter-related deep venous thrombosis in critically ill children.

OBJECTIVE: To determined the current incidence and acute complications of asymptomatic central venous catheter (CVC)-related deep venous thrombosis (DVT) in critically ill children. STUDY DESIGN: We performed a prospective cohort study in 3 pediatric intensive care units. A total of 101 children with newly inserted untunneled CVC were included. CVC-related DVT was diagnosed using compression ultrasonography with color Doppler. RESULTS: Asymptomatic CVC-related DVT was diagnosed in 16 (15.8%) children, which equated to 24.7 cases per 1000 CVC-days. Age was independently associated with DVT. Compared with children aged <1 year, children aged >13 years had significantly higher odds of DVT (aOR, 14.1, 95% CI, 1.9-105.8; P = .01). Other patient demographics, interventions (including anticoagulant use), and CVC characteristics did not differ between children with and without DVT. Mortality-adjusted duration of mechanical ventilation, a surrogate for pulmonary embolism, was statistically similar in the 2 groups (22 ± 9 days in children with DVT vs 23 ± 7 days in children without DVT; P = .34). Mortality-adjusted intensive care unit and hospital lengths of stay also were similar in the 2 groups. CONCLUSION: Asymptomatic CVC-related DVT is common in critically ill children. However, the acute complications do not seem to differ between children with and without DVT. Larger studies are needed to confirm these results. Future studies should also investigate the chronic complications of asymptomatic CVC-related DVT.

Design, validity, and reliability of a pediatric resident JumpSTART disaster triage scoring instrument.

OBJECTIVE: To design an instrument for scoring residents learning pediatric disaster triage (PDT), and to test the validity and reliability of the instrument. METHODS: We designed a checklist-based scoring instrument including PDT knowledge and skills and performance, as well as a global assessment. Learners' performance in a 10-patient school bus crash simulation was video recorded and scored with the instrument. Learners triaged the patients with a color-coded algorithm (JumpSTART, Simple Triage and Rapid Treatment). Three evaluators observed the recordings and scored triage performance for each learner. Internal and construct validity of the instrument were established via comparison of resident performance by postgraduate year (PGY) and correlating instrument items with overall score. Validity was assessed with analysis of variance and the D statistic. We calculated evaluators' intraclass correlation coefficient (ICC) for each patient, skill, triage decision, and global assessment. RESULTS: There were 37 learners and 111 observations. There was no difference in total scores by PGY (P = .77), establishing internal validity. Regarding construct validity, most instrument items had a D statistic of >0.5. The overall ICC among scores was 0.83 (95% confidence interval [CI] 0.74-0.89). Individual patient score reliability was high and was greatest among patients with head injury (ICC 0.86; 95% CI 0.79-0.91). Reliability was low for an ambulatory patient (ICC 0.29; 95% CI 0.07-0.48). Triage skills evaluation showed excellent reliability, including airway management (ICC 0.91; 95% CI 0.86-0.94) and triage speed (ICC 0.81; 95% CI 0.72-0.88). The global assessment had moderate reliability for skills (ICC 0.63; 95% CI 0.47-0.75) and knowledge (ICC 0.64; 95% CI 0.49-0.76). CONCLUSIONS: We report the validity and reliability testing of a PDT-scoring instrument. Validity was confirmed with no performance differential by PGY. Reliability of the scoring instrument for most patient-level triage, knowledge, and specific skills was high.

Analysis of coronary artery dosimetry in the 3-dimensional era: Implications for organ-at-risk segmentation and dose tolerances in left-sided tangential breast radiation.

PURPOSE: To evaluate the dose to the left anterior descending artery in patients receiving left-sided tangential breast radiation. METHODS AND MATERIALS: The study cohort consisted of 50 left-sided breast cancer patients who were sequentially simulated at our institution. The heart and left anterior descending (LAD) artery were contoured from its origin on the left main coronary artery down to the last visible segment of the vessel. Detailed dosimetry of the heart and LAD artery were obtained and analyzed. RESULTS: Excellent correlation between the dose to the heart and LAD artery was discovered. The mean LAD dose was 17.98 Gy. The mean dose to the proximal LAD was 2.46 Gy. The median V25 was 2.91% and the mean heart dose 3.10 Gy. For every 100 cGy increase in mean heart dose, mean LAD dose increased by 4.82 Gy. For every percent increase in the heart V10 and V25, there was a 2.23 Gy and 2.77 Gy increase in mean LAD dose, respectively. For every percent increase of heart V25, a 5.6% increase in the LAD V20 was demonstrated. CONCLUSIONS: The LAD artery dose correlates very closely with all of the commonly measured heart dose constraints, and does not need to be contoured separately when standard tangential borders are used. Incidental LAD artery doses remain with supine breast tangential radiation therapy.

Improving organizational climate for quality and quality of care: does membership in a collaborative help?

BACKGROUND: The lack of quality-oriented organizational climates is partly responsible for deficiencies in patient-centered care and poor quality more broadly. To improve their quality-oriented climates, several organizations have joined quality improvement collaboratives. The effectiveness of this approach is unknown. OBJECTIVE: To evaluate the impact of collaborative membership on organizational climate for quality and service quality. SUBJECTS: Twenty-one clinics, 4 of which participated in a collaborative sponsored by the Institute for Clinical Systems Improvement. RESEARCH DESIGN: Pre-post design. Preassessments occurred 2 months before the collaborative began in January 2009. Postassessments of service quality and climate occurred about 6 months and 1 year, respectively, after the collaborative ended in January 2010. We surveyed clinic employees (eg, physicians, nurses, receptionists, etc.) about the organizational climate and patients about service quality. MEASURES: Prioritization of quality care, high-quality staff relationships, and open communication as indicators of quality-oriented climate and timeliness of care, staff helpfulness, doctor-patient communication, rating of doctor, and willingness to recommend doctor's office as indicators of service quality. RESULTS: There was no significant effect of collaborative membership on quality-oriented climate and mixed effects on service quality. Doctors' ratings improved significantly more in intervention clinics than in control clinics, staff helpfulness improved less, and timeliness of care declined more. Ratings of doctor-patient communication and willingness to recommend doctor were not significantly different between intervention and comparison clinics. CONCLUSION: Membership in the collaborative provided no significant advantage for improving quality-oriented climate and had equivocal effects on service quality.

Human POLB gene is mutated in high percentage of colorectal tumors.

Previous small scale sequencing studies have indicated that DNA polymerase ß (pol ß) variants are present on average in 30% of human tumors of varying tissue origin. Many of these variants have been shown to have aberrant enzyme function in vitro and to induce cellular transformation and/or genomic instability in vivo, suggesting that their presence is associated with tumorigenesis or its progression. In this study, the human POLB gene was sequenced in a collection of 134 human colorectal tumors and was found to contain coding region mutations in 40% of the samples. The variants map to many different sites of the pol ß protein and are not clustered. Many variants are nonsynonymous amino acid substitutions predicted to affect enzyme function. A subset of these variants was found to have reduced enzyme activity in vitro and failed to fully rescue pol ß-deficient cells from methylmethane sulfonate-induced cytotoxicity. Tumors harboring variants with reduced enzyme activity may have compromised base excision repair function, as evidenced by our methylmethane sulfonate sensitivity studies. Such compromised base excision repair may drive tumorigenesis by leading to an increase in mutagenesis or genomic instability.

Neutrophil CD64 as a diagnostic marker in neonatal sepsis.

We assessed neutrophil CD64 as a diagnostic marker for neonatal sepsis. For early-onset sepsis, the CD64 index with a cut-point value of 2.38 had sensitivity, specificity and negative predictive values of 100%, 68% and 100%, respectively. For late-onset sepsis, the respective values were 3.62, 75%, 77% and 96%. Neutrophil CD64 index can be incorporated as a valuable marker for excluding neonatal sepsis.

Transport disposition using the Transport Risk Assessment in Pediatrics (TRAP) score.

BACKGROUND: Determining appropriate disposition for referred pediatric patients is difficult, since it relies primarily on a telephone description of the patient. In this study, we evaluate the Transport Risk Assessment in Pediatrics (TRAP) score's ability to assist in appropriate placement of these patients. This novel tool is derived from physiologic variables. OBJECTIVES: To determine the feasibility of calculating a TRAP score and whether a higher score correlates with pediatric intensive care unit (PICU) admission. METHODS: We performed an observational study of pediatric patients transported by a specialized team to a tertiary care center and the feasibility of implementing the TRAP tool. Patients were eligible if transported by the pediatric specialty transport team for direct admission to the children's hospital. The TRAP score was obtained either through chart review of the transport team's initial assessment or in real time by the transport team. RESULTS: A total of 269 patients were identified, with 238 patients included in the study. Using logistic regression, higher TRAP scores were associated with PICU admission (odds ratio [OR] 1.40, p < 0.001). Patients with a higher score were also less likely to leave the PICU within 24 hours (OR 0.79, p < 0.001). CONCLUSION: The TRAP score is a novel objective pediatric transport assessment tool where an elevated score is associated with PICU admission for more than 24 hours. This score may assist with the triage decisions for transported pediatric patients.

Risk factors associated with biliary pancreatitis in children.

OBJECTIVES: Little is known about risk factors for biliary pancreatitis in children. We characterized cases of pediatric biliary pancreatitis, compared biliary with nonbiliary cases, examined differences in presentation between younger and older children, and studied features distinguishing gallstone- from sludge-induced pancreatitis. METHODS: We evaluated 76 episodes of biliary pancreatitis from 271 cases of acute pancreatitis in children admitted to a tertiary care hospital from 1994 to 2007. RESULTS: Of the 76 cases, 55% had gallstones, 21% had sludge, and 24% had structural defects. Hispanic children had 2.85 (P = 0.01) and 5.59 (P = 0.003) times higher probability for biliary pancreatitis than white and black children, respectively. Median serum amylase and lipase in children with biliary pancreatitis were 64% and 49% higher, respectively, compared with other causes (P < 0.05). In multiple logistic regression, aspartate aminotransferase was an independent predictor of biliary pancreatitis (odds ratio 6.69, P = 0.001). When comparing gallstone- with sludge-induced causes, obesity was an independent predictor (38% more prevalent, P < 0.01) of gallstone cases. CONCLUSIONS: Hispanic ethnicity is a risk factor and aspartate aminotransferase is a biomarker for biliary pancreatitis over other causes. Furthermore, obesity can distinguish gallstone- from sludge-induced pancreatitis. These findings may spur prospective studies to determine the optimal evaluation and management of children with biliary pancreatitis.

Remember the saphenous: ultrasound evaluation and intravenous site selection of peripheral veins in young children.

OBJECTIVES: The primary objective of this study was to measure the width and depth of peripheral veins using bedside ultrasound in children younger than 3 years. Secondary objectives included the evaluation of other vein and patient characteristics that may affect intravenous (IV) site selection. Assessment of nursing preferences for peripheral IV site selection was performed. METHODS: Sixty children aged 0 to 3 years who presented to an urban pediatric emergency department were enrolled. Ultrasound measurements of the transverse diameter (width) and distance from the top of the vein to the skin (depth) were recorded. Upon examination, veins were categorized as visible, palpable, detectable only by ultrasound, or not detectable. Sixteen staff nurses rated the likelihood of successful IV placement among different peripheral veins. RESULTS: The mean width of saphenous veins was significantly larger than that of hand veins (2.8 vs 1.8 mm, P < 0.0001). When comparing saphenous veins to antecubital veins, no significant difference was measured between the mean width (2.8 vs 2.8 mm). The mean depth of saphenous veins was significantly greater than those of hand veins (1.9 vs 1.4 mm, P < 0.0001) and antecubital veins (1.9 vs 1.6 mm, P = 0.019). Differences in visibility and palpability were observed between different vein types. Hand veins and antecubital veins were rated by the nursing staff as the most likely sites for successful IV placement, whereas saphenous veins were among the least likely (P < 0.0001). CONCLUSIONS: In children younger than 3 years, the saphenous vein is larger than hand veins and is similar in size to antecubital veins, although marginal differences in depth exist. The sonographic findings of the saphenous vein and antecubital vein suggest that either should be considered a superior first choice for IV cannulation in this age group. Knowledge of these differences is important when choosing a site for peripheral IV placement. Future studies should evaluate peripheral IV success rates by vein type with or without ultrasound guidance.

Time to and Predictors of CD4+ T-Lymphocytes Recovery in HIV-Infected Children Initiating Highly Active Antiretroviral Therapy in Ghana.

Background. CD4+ T-lymphocyte monitoring is not routinely available in most resource-limited settings. We investigated predictors of time to CD4+ T-lymphocyte recovery in HIV-infected children on highly active antiretroviral (HAART) at Korle-Bu Teaching Hospital, Ghana. Methods. Time to CD4+ T-lymphocyte recovery was defined as achieving percent CD4+ T-lymphocytes of 25%. We used Cox proportional hazard models for identifying significant predictor variables. Results. Of the 233 children with complete CD4+ T-lymphocyte data, the mean age at HAART initiation was 5.5 (SD = 3.1) years. The median recovery time was 60 weeks (95% CL: 55-65). Evidence at baseline of severe suppression in CD4+ T-lymphocyte count adjusted for age, age at HAART initiation, gender, and having parents alive were statistically significant in predicting time to CD4+ T-lymphocyte recovery. Conclusions. A targeted approach based on predictors of CD4+ T-lymphocyte recovery can be a viable and cost-effective way of monitoring HAART in HIV-infected children in resource-limited settings.

A randomized controlled trial of capnography in the correction of simulated endotracheal tube dislodgement.

OBJECTIVES: Unrecognized dislodgement of an endotracheal tube (ETT) during the transport of an intubated patient can have life-threatening consequences. Standard methods to monitor these patients, such as pulse oximetry and physical examination, are both subject to inaccuracies with patient movement and ambient noise. Capnography provides a continuous and objective measure of ventilation that can alert a provider immediately to an airway problem. The objective of this study was to determine through simulation if capnography decreases time to correction of dislodged ETTs during the transport of intubated patients, in comparison to standard monitoring. METHODS: Paramedics and paramedic students were randomized as to whether or not they had capnography available to them in addition to standard monitoring during a simulated scenario. In the scenario, subjects monitored an intubated baby who subsequently experiences a dislodgement of the ETT during interfacility transport. Time to correction of the ETT dislodgement was the primary outcome. The secondary outcome was correction of dislodgement prior to decline in pulse oximetry. RESULTS: Fifty-three subjects were enrolled in the study, with complete data on 50 subjects. Median time to correction of ETT dislodgement was 2.02 minutes (95% confidence interval [CI] = 1.22 to 4.12 minutes) for the capnography group versus 4.00 minutes (95% CI = 3.35 to 5.50 minutes) in the standard monitoring group (p = 0.05). Forty-eight percent of subjects using capnography corrected the ETT dislodgement prior to decline in pulse oximetry compared with 12% of controls (p = 0.01). There were no differences in time to correction of dislodgement based on years of experience, perceived comfort, reported adequacy of teaching, or past use of capnography. CONCLUSIONS: The addition of capnography to standard monitoring significantly improves recognition of ETT dislodgement and reduces the time to correction of dislodged ETTs by prehospital providers in a simulated pediatric transport setting.

Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis.

OBJECTIVE: To determine whether duration of antibiotic exposure is an independent risk factor for necrotizing enterocolitis (NEC). STUDY DESIGN: A retrospective, 2:1 control-case analysis was conducted comparing neonates with NEC to those without from 2000 through 2008. Control subjects were matched on gestational age, birth weight, and birth year. In each matched triad, demographic and risk factor data were collected from birth until the diagnosis of NEC in the case subject. Bivariate and multivariate analyses were used to assess associations between risk factors and NEC. RESULTS: One hundred twenty-four cases of NEC were matched with 248 control subjects. Cases were less likely to have respiratory distress syndrome (P = .018) and more likely to reach full enteral feeding (P = .028) than control subjects. Cases were more likely to have culture-proven sepsis (P < .0001). Given the association between sepsis and antibiotic use, we tested for and found a significant interaction between the two variables (P = .001). When neonates with sepsis were removed from the cohort, the risk of NEC increased significantly with duration of antibiotic exposure. Exposure for >10 days resulted in a nearly threefold increase in the risk of developing NEC. CONCLUSIONS: Duration of antibiotic exposure is associated with an increased risk of NEC among neonates without prior sepsis.

Survey of pharmacologic thromboprophylaxis in critically ill children.

OBJECTIVE: There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit. We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children. SETTING: Pediatric intensive care units in the United States and Canada with at least ten beds. DESIGN: Cross-sectional self-administered survey of pediatric intensivists using adolescent, child, and infant scenarios. PARTICIPANTS: Pediatric intensive care unit clinical directors or section heads. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Physician leaders from 97 of 151 (64.2%) pediatric intensive care units or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all pediatric intensive care unit patients, 3.1%, 32.0%, and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child, and infant scenarios, respectively. These findings were significant (p < .001 for the adolescent vs. child and infant; p = .002 for child vs. infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all three scenarios were the presence of hypercoagulability, prior deep venous thrombosis, or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low-molecular-weight heparin was the most commonly prescribed drug. CONCLUSIONS: In these scenarios, physician leaders in pediatric intensive care units were more likely to prescribe thromboprophylaxis to adolescents compared with children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.

Mortality-adjusted duration of mechanical ventilation in critically ill children with symptomatic central venous line-related deep venous thrombosis.

OBJECTIVE: To determine the association between symptomatic central venous line-related deep venous thrombosis and a mortality-adjusted measure of duration of mechanical ventilation in critically ill children with central venous lines. DESIGN: Retrospective matched cohort study. SETTING: Eleven pediatric intensive care units across the United States. PATIENTS: Twenty-nine index critically ill children with central venous line-related deep vein thrombosis from a previous prospective observational study on symptomatic venous thromboembolism were compared with 116 control children with central venous lines without venous thrombosis. Each index patient was matched to four control patients based on age group, disease category, severity of illness score, and number of days in the intensive care unit before central venous line insertion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Index patients were appropriately matched to control patients with similar characteristics between the two groups. Index patients had fewer ventilator-free days (ie, days alive and breathing unassisted within 28 days after central venous line insertion) compared with matched control patients (16.8 ± 11.5 days vs. 22.3 ± 4.9 days, p = .040). Index patients also had less intensive care unit-free days (ie, days alive and discharged from the intensive care unit within 28 days after central venous line insertion) (9.8 ± 9.9 days vs. 17.9 ± 5.7 days, p < .001). Durations of mechanical ventilation (17.6 ± 40.6 days vs. 5.2 ± 5.5 days, p = .236) and intensive care unit stay (38.1 ± 61.7 days vs. 11.9 ± 10.9 days, p = .011) were longer in index patients. The mortality rate was statistically similar between the two groups. CONCLUSIONS: The presence of symptomatic central venous line-related deep vein thrombosis is associated with worse outcomes, particularly fewer ventilator-free days, in critically ill children. The causal relationship that deep venous thrombosis leads to impairment in lung function and delays weaning from mechanical ventilation and discharge from the intensive care unit needs to be proven prospectively. Ventilator-free days is a possible alternative outcome measure for future deep venous thrombosis studies.