Social inequities impact infant mortality due to congenital heart disease.

OBJECTIVES: To evaluate how educational, economic, and racial residential segregation may impact congenital heart disease infant mortality (CHD-IM). STUDY DESIGN: This is a population-based US ecological study. METHODS: This study evaluated linked live birth-infant death files from the National Center for Health Statistics for live births from 2006 to 2018 with cause of death attributed to CHD. Maternal race and education data were obtained from the live birth-infant death files, and income data were obtained from the American Community Survey. A spatial social polarization measure termed the Index of Concentration at the Extremes (ICE) was calculated and split by quintiles for maternal education, household income, and race for all US counties (n = 3142). The lowest quintile represents counties with highest concentration of disadvantaged groups (income < $25K, non-Hispanic Black, no high school degree). Proximity to a pediatric cardiac center (PCC) was also analyzed in a categorical manner based on whether each county was in a metropolitan area with a US News and World Report top 50 ranked PCC, a lower ranked PCC, or not proximal to any PCC. RESULTS: Between 2006 and 2018, 17,489 infant deaths were due to CHD, an unadjusted CHD-IM of 0.33 deaths per 1000 live births. The risk of CHD-IM was 1.5 times greater among those in the lowest ICE-education quintile (0.41 [0.39-0.44] vs 0.28 deaths/1000 live births [0.27-0.29], P < 0.0001) and the lowest ICE-income quintile (0.44 [0.41-0.47] vs 0.29 [0.28-0.30], P < 0.0001) in comparison to those in the highest quintiles. CHD-IM increases with higher ICE-race value (counties with a higher concentration of non-Hispanic White mothers). However, after adjusting for proximity to a US News and World Report top 50 ranked PCC in the multivariable models, CHD-IM decreases with higher ICE-race value. CONCLUSIONS: Counties with the highest concentration of lower-educated mothers and the highest concentration of low-income households were associated with higher rates of CHD-IM. Mortality as a function of race is more complicated and requires further investigation.

Catheter-related infection in Irish intensive care units diagnosed with HELICS criteria: a multi-centre surveillance study.

BACKGROUND: Catheter-related infection (CRI) surveillance is advocated as a healthcare quality indicator. However, there is no national CRI surveillance programme or standardized CRI definitions in Irish intensive care units (ICUs). AIM: To examine the feasibility of multi-centre CRI surveillance in nine Irish ICUs, using Hospitals in Europe Link for Infection Control through Surveillance (HELICS) definitions (CRI 1, CRI 2 and CRI 3). METHODS: All non-tunnelled central venous catheters (CVCs) inserted in patients aged >18 years with an ICU stay ≥48 h were included over a three-month study period. FINDINGS: Feasibility was demonstrated by the 99.5% return rate for study forms. Data on 1209 CVCs in 614 patients over 7587 CVC-days showed 17 episodes of CRI, representing a national rate of 2.2 per 1000 CVC-days [95% confidence interval (CI) 1.2-3.3]. Rates of CRI 1, CRI 2 and CRI 3 were 0.13 (95% CI 0.00-0.39), 0.79 (95% CI 0.16-1.42) and 1.39 (95% CI 0.60-2.17) per 1000 CVC-days, respectively. CRI was associated with length of ICU stay (P < 0.001), number of CVCs inserted (P < 0.001) and total number of CVC-days per patient (P < 0.001). CRI was higher in CVCs inserted in operating theatres (incident rate ratio 3.9, 95% CI 1.3-11.5; P = 0.02) compared with CVCs inserted in ICUs. Participant feedback reported minimal difficulty with surveillance implementation, and data collection required approximately 1 h per patient per week. CONCLUSION: The study demonstrated that multi-centre ICU surveillance using HELICS CRI definitions was practical, feasible and provided clinically relevant information. CRI surveillance in ICUs, although labour intensive, is recommended to reduce CRI and allow ongoing evaluation of processes aimed at CRI reduction.

De novo donor specific antibodies and patient outcomes in renal transplantation.

Single antigen identification of HLA antibodies is used to detect donor specific antibodies (DSAs). However, the impact of DSA elements such as class, relative strength, duration, and longitudinal effect on graft function and survival, remains unclear. Routine DSAs (LabScreen, One Lambda, Inc., Canoga Park, CA) and metabolic studies were performed at 1, 3, 6, 9, and 12 months post-transplant, and every 6 months for renal transplant recipients from 7/2007-7/2010 (n = 389). Biopsies were evaluated by updated Banff 2005 guidelines after two consecutive positive DSAs. Based on these tests, 25% of recipients developed de novo DSA. Those with DSA had increased acute rejection episodes (AR), higher creatinine (Scr), and worse graft survival. Three subgroups of these patients were identified based on duration: persistent DSA (> 1), isolated DSA, or no DSA. Persistent DSA patients were more likely to be African American, and have higher mean fluorescence intensity (MFI) and AR rates. Persistent DSA patients, with or without AR, had elevated Scr. Recipients with DQ-only DSA had higher rates of antibody mediated rejection (AMR). From this, we conclude that routine posttransplant DSA monitoring identifies recipients at risk for graft damage or loss. Persistent de novo DSAs correlated with inferior graft outcomes and AMR. With or without AR, DSA persistence was associated with worse outcomes, possibly warranting intervention. De novo DQ-DSA may be a biomarker for chronic damage and/or AMR, while an isolated DSA determination appears clinically insignificant.

Same place, different experience: nurses and residents on pediatric emergency transport.

A questionnaire was mailed to nurse transport coordinators at the 76 United States pediatric training programs listing 35 pediatric residents or more, and a related but different questionnaire was mailed to chief pediatric residents at the same centers. Comparisons of responses to a series of questions on the role of the nurse on transport suggest that the pediatric emergency transport team offers an excellent opportunity to implement collaborative practice strategies between nurses and residents. Both groups stated the value of professional discussion and consultation to derive mutually satisfactory resolutions to patient care issues. Physician respondents indicated a genuine respect for the nurses' skill and expanded role in the care of critically ill children during transport. The transport experience offers a window of opportunity for nurses and physicians interested in developing research and practice models aimed at fostering collaboration between nurses and physicians-in-training.

The educational value of pediatric emergency transport: by design or by default?

Pediatric emergency transport teams provide an important and challenging clinical experience in many residency training programs. However, the educational value of this experience has not been carefully examined. A 32-item questionnaire was developed to assess curricular components of the three phases of the transport experience in residency training: phase 1 included pretransport training and qualifications and curricular planning, phase 2 addressed intratransport phone backup for the team analogous to online medical command, and phase 3 included posttransport feedback and performance evaluation. The study also addressed the chief residents' perception of the roles of the resident and transport nurse working on the team. The survey was mailed to chief residents at 76 pediatric residency programs in the United States. Data were received from 75 programs for a return rate of 98%. Fifty-four programs that used residents for transport team staffing were analyzed using descriptive statistics. Of the respondents, 39% report a specific training process prior to transport. Twenty-two percent of programs provide residents with written materials such as a manual or course syllabus. Eighty-two percent have a senior physician always identified for phone backup. Fifty-two percent of programs have no specific method for team evaluation and 31% rely only on informal verbal feedback. Thirty percent routinely provide feedback within one week of the transport. Sixty-three percent of chief residents view the experienced transport nurse as an equal member of the transport team. The study found that the educational structure of transports is largely unplanned and that basics such as preservice training and timely performance feedback are not usually addressed.(ABSTRACT TRUNCATED AT 250 WORDS)

Vasoactive drug therapy in shock.

The process of supporting the patient in shock with vasoactive infusions is never a static one. There are a variety of vasoactive infusions available; unfortunately, no one medication effectively corrects the numerous abnormalities in all forms of shock and no magic formula exists for combining medications to achieve optimum tissue perfusion. The nurse is challenged to utilize keen assessment skills and sophisticated monitoring techniques to follow the patient's response to changing vasoactive drug therapy. The nurse must collaborate with the physician and other health team members to integrate drug therapy with the other aspects of shock therapy, including fluid repletion, oxygenation and ventilation, metabolic support, and antibiotic therapy to facilitate the successful resuscitation of the patient in shock.

Pain in home hospice patients: an exploratory descriptive study.

A descriptive, exploratory study was conducted to determine the prevalence, severity, and relationship of pain to the physical, psychological, social, and spiritual dimensions of hospice patients. From retrospective analysis of initial treatment plans, one hundred subjects were divided into a pain (N = 58) and a non-pain (N = 42) group. Group differences were determined through percentage and chi-square analysis of observed frequencies. Findings on the prevalence, severity, and presence of pain in far-advanced cancer were consistent with those previously reported. The pain group demonstrated significant differences in number of metastatic lesions, physical limitations, alterations in elimination, and alterations in nutrition. The number of subjects completing legal and funeral arrangements was significantly higher for the pain group.

Differential sensitivity of antinociceptive tests to opioid agonists and partial agonists.

1. The antinociceptive activity of a range of opioid agonists and agonist-antagonist analgesics was determined in mice by use of the 55 degrees C hot plate and abdominal constriction assays. 2. Opioid agonists were approximately 10 times more effective in the abdominal constriction assay. 3. The agonist-antagonists produced analgesia only in the abdominal constriction assay, and antagonized the antinociceptive action of opioid agonists in the 55 degrees C hot plate test. 4. These differences were shown to be attributable to the different levels of stimulus employed in the two tests. 5. By comparing the antagonist potencies of the agonist-antagonists in the 55 degrees C hot plate test with their antinociceptive ED50 values in the abdominal constriction assay, an index of intrinsic activity was calculated.

Ear asymmetry for monaurally presented word lists in children and adults.

In order to study ear asymmetry during monaural stimulation, 80 listeners were asked to recall the word which followed a probe word in 40, 10-word lists. Subjects were divided into four age groups: 7-9, 13-16, 25-30, and 60+ years. Probe words occurred in early (position 2) or late (position 7) in each 10 word list. Superior recall accuracy was shown when words were presented to the right ear of 48 subjects. 12 subjects demonstrated superior left ear performance, and 20 subjects performed equally well in each ear. Subjects showing superior right ear performance also demonstrated superior overall performance. Older children and younger adults performed significantly better than younger children or older adults. The factor of subject sex was not significant. Ear asymmetry during monaural stimulation appeared to be related to competition between incoming and rehearsed stimuli during central memory processing.

Ear asymmetry for recall of monaurally presented words.

In order to test for ear asymmetry using monaural stimulation, 30 adult listeners were presented a series of ten-word lists and asked to recall words from early (position three) and late (position eight) positions in each list. Significantly better performance was obtained when the word lists were presented to the right ear of the subjects. Words occurring in position eight were recalled more accurately than words that occurred in position three. Ear asymmetry during monaural stimulation appeared to be related, at least in part, to competition between incoming and rehearsed stimuli during central memory processing.