Influence of Evidence-Based Design Strategies on Nurse Wellness.

OBJECTIVES: The purpose of this study was to understand how specific evidence-based design strategies are related to aspects of nurse wellness. BACKGROUND: Addressing burnout among the healthcare workforce is a system-level imperative. Nurses face continuous and dynamic physical and emotional demands in their role. Greater insight into the role of the physical environment can support efforts to promote nurse wellness. METHODS: This exploratory qualitative study was conducted at new Parkland Hospital in Dallas, TX. We conducted five focus groups with nursing staff in July 2018. These sessions covered five topics related to nursing work in the facility which had been redesigned nearly 3 years earlier: (1) professional and social communication, (2) workflow and efficiency, (3) nurses' tasks and documentation, (4) ability to care for patients, and (5) nurses' overall health. We conducted a thematic analysis and first identified different aspects of wellness discussed by participants. Then, we examined how nurses related different design elements to different aspects of their wellness. RESULTS: Participants included 63 nurses and nurse managers. They related environmental factors including facility size, break rooms, and decentralized workstations to social, emotional/spiritual, physical, intellectual, and occupational aspects of wellness. CONCLUSIONS: It is critical to inform and integrate nurses at all levels into planning, design, and activation of new healthcare environments in order to ensure the well-being of nurses and, therefore, their ability to effectively support patients.

A Review of the Effectiveness of Audio-Only Telemedicine for Chronic Disease Management.

Background: The clinical effectiveness of audio-only telemedicine has not been fully quantified. The pandemic afforded a unique situation to retrospectively observe clinical outcomes of care for three disease cohorts within three care models, including audio-only telemedicine. Methods: Patients were classified into three care models: audio-only telemedicine, in-person, and hybrid. Each model was compared with an aggregate group before the onset of the pandemic and within each group during the pandemic. Each disease cohort was evaluated in cross-sectional and paired analyses. Results: Patients (n = 52,720) were grouped within one of three care models. A majority (n = 48,335) of patients qualified for the "pre" group comparison. The audio-only telemedicine care model showed similar control of renal disease, hypertension control, and diabetes management than in-person and hybrid care models. Conclusions: Audio-only telemedicine appears to be noninferior to in-person or hybrid models for chronic disease management for the diseases studied. In all instances, it had similar control compared with the in-person care model. We acknowledge the limitations of this study, including convenience sampling and a limited observation timeframe. Audio-only telemedicine should be considered a viable care model modality that can be integrated into options for patient care. Further study and investment are warranted, as it provides efficacy and convenience to health systems (Clinical Registration Number # 32449).

From Fable to Reality at Parkland Hospital: The Impact of Evidence-Based Design Strategies on Patient Safety, Healing, and Satisfaction in an Adult Inpatient Environment.

OBJECTIVE: This research aimed to evaluate the quantitative effects of new hospital design on adult inpatient outcomes. BACKGROUND: Tenets of evidence-based healthcare design, notably single-patient acuity-adaptable and same-handed rooms, decentralized nursing stations, onstage offstage layout, and access to nature were expected to promote patient healing and increase patient satisfaction, while decreasing adverse events. METHODS: Patient healing was operationalized through length of stay (LOS) and patient safety through three adverse events: falls, hospital-acquired infections (HAI), and medication-related events. Standard patient surveys captured patient satisfaction. Patient records from 2013 through 2017 allowed for equivalent time periods surrounding the move to the new hospital in August 2015. Stratified by hospital division where significant, pre/post comparisons utilized proportional hazards or logistic regression models as appropriate; interrupted time series analyses afforded longitudinal interpretations. RESULTS: Observed higher postmove LOS was due to previously increasing trends, not increases after the move. In surgical and trauma units, a constant increase in falls was unaffected by the move. Medication events decreased consistently over time; medication events with harm dropped significantly after the move. No change in HAI was found. Significant improvement on most relevant patient satisfaction items occurred after the move. Call button response decreased immediately after the move but subsequently improved. CONCLUSION: Results did not clearly indicate a net change in adult inpatient outcomes of healing and safety due to the hospital design. There was evidence that the new hospital improved patient satisfaction outcomes related to the environment, including comfort, noise, temperature, and aesthetics.

Single-family room neonatal intensive care unit design: do patient outcomes actually change?

OBJECTIVE: This study examined outcomes in a single-family room neonatal intensive care unit (NICU) compared to an open bay within a public safety net hospital. STUDY DESIGN: We included 9995 NICU encounters over 5 years pre and post move for a predominantly low SES population. Outcomes were length of stay (LOS), growth, time to first oral feeding, and incidence of sepsis. Analysis included regression models, interrupted time series, and growth models. RESULTS: LOS decreased over time in preterm infants both pre and post move, but increased post move for term/post-term infants (p < 0.001). First oral feeding decreased over time in both periods. A higher incidence of sepsis was found in the post period for term/post-term infants (p = 0.01). CONCLUSION: Our analysis appropriately accounted for time trends. Few differences were observed. Changes in LOS for term/post-term infants should be further explored as well as the impact of NICU care patterns.

From Competition to Collaboration: How a Multi-Firm Research Coalition Is Realizing Rigorous Facility Evaluation at Parkland Hospital.

This case study presents the process of developing a multi-entity Research Coalition to evaluate the new Parkland Hospital. The field of evidence-based design has made progress in systematically investigating relationships between healthcare facility design and a range of human outcomes. Yet healthcare facility evaluation is not typically included in the scope of building contracts. Lack of clear responsibility for evaluation and limited funding have been long-term barriers that the industry has yet to overcome. Firms engaged in design research at Parkland Hospital agreed with hospital representatives to collaborate on an integrated facility evaluation. Each participating entity contributed resources toward the effort. To formalize shared goals and priorities, the group developed a Research Coalition Charter. Goals included streamlining evaluation efforts to minimize burden on the hospital, leveraging multiple expertise areas to vet research aims and approaches, contributing knowledge to inform healthcare design, and innovating a model for multi-firm collaboration. The Coalition also developed guidelines for sharing data and disseminating research findings. To date, the Research Coalition has achieved key milestones including institutional review board exemption, data use and research collaboration agreements, and data collection. The research aims encompass patient and staff outcomes hypothesized to improve in the new facility. Both primary and secondary data are being analyzed to test the hypotheses. Publications of findings are forthcoming. Collaborative research among competitors may be a viable approach to realizing evaluation that is critical to learning for healthcare facility decision makers and design practitioners.

Reducing Hospitalizations: Institution of Outpatient Infusional EPOCH-Based Chemotherapy at a Safety Net Hospital.

PURPOSE: EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) -based chemotherapy is traditionally administered inpatient because of its complex 96-hour protocol and number of involved medications. These routine admissions are costly, disruptive, and isolating to patients. Here, we describe our experience transitioning from inpatient to outpatient ambulatory EPOCH-based chemotherapy in a safety-net hospital, associated cost savings, and patient perceptions. METHODS AND MATERIALS: Guidelines for chemotherapy administration and educational materials were developed by a multidisciplinary team of physicians, nurses, and pharmacists. Data were collected via chart review and costs via the finance department. Patient satisfaction with chemotherapy at home compared with hospitalization was measured on a Likert-type scale via direct-to-patient survey. RESULTS: From January 30, 2017, through January 30, 2018, 87 cycles of EPOCH-based chemotherapy were administered to 23 patients. Sixty-one ambulatory cycles (70%) were administered to 18 patients. Of 26 cycles administered in the hospital, 18 (69%) were the first cycle of treatment. Rates of inappropriate prophylactic antimicrobial prescription and laboratory testing were lower in the outpatient setting. Eight of nine patients surveyed preferred home chemotherapy to inpatient chemotherapy. Per-cycle drug costs were 57.6% lower in outpatients as a result of differences in the acquisition cost in the outpatient setting. In total, the transition to ambulatory EPOCH-based chemotherapy yielded 1-year savings of $502,030 and an estimated 336 days of avoided hospital confinement. CONCLUSION: Multiday ambulatory EPOCH-based regimens were successfully and safely administered in our safety-net hospital. Outpatient therapy was associated with significant savings through avoided hospitalizations and reductions in drug acquisition cost and improved patient satisfaction.

Physician-Specific Practice Patterns About Discharge Readiness and Heart Failure Utilization Outcomes.

BACKGROUND: Although hospitalization for acute decompensated heart failure (HF) is common and associated with poor outcomes and high costs, few evidence-based recommendations are available to guide patient management. Thus, management of inpatient HF remains heterogeneous. We evaluated if physician-specific self-reported HF practice patterns were associated with 2 important contributors to resource utilization: length of stay (LOS) and 30-day readmission. METHODS AND RESULTS: A 5-point Likert scale survey was created to assess physician-specific HF discharge strategies and administered to all cardiologists and hospitalists at a single large academic teaching hospital. Practice patterns potentially impacting LOS and discharge decisions were queried, including use of physical examination findings, approaches to diuretic use and influence of kidney function. Likert scale responses are reported as means with any value above 3.00 considered more influential and any value below 3.00 considered less influential. Physician-specific LOS and 30-day readmission rates from July 1, 2015, to June 30, 2016, were extracted from the electronic record. We received survey responses and HF utilization metrics from 58 of 69 surveyed physicians (32 hospitalists and 26 cardiologists), encompassing 753 HF discharges over a 1-year period. Median LOS was 4.5 days (interquartile range, 4.0-5.8) and total 30-day readmission rate was 17.0% (128 unique readmissions). Physicians with below-median LOS placed less importance on observing a patient on oral diuretics for 24 hours before discharge (Likert 2.54 versus 3.30, P=0.01), reaching documented dry weight (Likert 2.93 versus 3.60, P=0.02), and complete resolution of dyspnea on exertion (Likert 3.64 versus 4.10, P=0.03) when compared with those above-median LOS. In contrast, no surveyed discharge practices were associated with physician-specific 30-day readmission. CONCLUSIONS: We identified specific inpatient HF discharge practice patterns that associated with shorter LOS but not with readmission rates. These may be targets for future interventions aimed at cost reduction; additional larger studies are needed for further exploration.

Identification of peanuts and tree nuts: are allergists smarter than their patients?

BACKGROUND: It has been reported that peanut- or tree nut-allergic individuals and their guardians are poorly capable of differentiating various tree nuts and peanuts. No information exists on the ability of allergists to differentiate peanuts and tree nuts. OBJECTIVE: To measure the ability of allergists and other specialists within the allergy and immunology field to identify various types of tree nuts and peanuts. METHODS: A nut box with a clear cover was constructed and contained various tree nuts and peanuts in shelled and unshelled forms. Attendees at the 2012 national meeting of the American Academy of Allergy, Asthma, and Immunology were offered participation by viewing the nut box and filling in their responses to a questionnaire. A similar procedure was conducted in the Food Allergy Center at Children's Medical Center (Dallas, TX) for guardians of children with and without peanut or tree nut allergies. RESULTS: Allergists were better able to identify and differentiate tree nuts and peanuts than guardians of peanut- or tree nut-allergic children, guardians of children without food allergies, and allergy and immunology fellows in training. CONCLUSION: It is important for allergists to educate peanut- and tree nut-allergic individuals and their guardians on the proper avoidance of peanuts and tree nuts. This includes education in the ability to identify peanuts and tree nuts. In addition, allergy and immunology fellows in training may benefit from education in proper peanut and tree nut identification.

Adverse reactions during drug challenges: a single US institution's experience.

BACKGROUND: Drug challenge is a useful tool when diagnostic testing lacks predictive value for a questionable history of drug allergy. Placebo-controlled drug challenge studies demonstrate that a significant number of patients report purely subjective symptoms to placebo. OBJECTIVE: To evaluate the safety and rate of adverse effects when performing drug challenges and to identify predictive factors for occurrences of subjective symptoms during drug challenges. METHODS: We performed a 6-year, retrospective medical record review of patients who underwent drug challenges by members of the Allergy and Immunology Division after consultation deemed drug challenges to be appropriate. Statistical analysis was performed to compare the proportion of patients with subjective symptoms based on certain factors, including sex, age, number of listed drug allergies, interval from historical drug reaction to the drug challenge, and types of historical reaction. RESULTS: A total of 114 patients underwent 123 drug challenges. Only 1 patient was deemed to have a true positive drug challenge result. Twenty patients reported subjective symptoms during graded challenge, all of which were not deemed a positive challenge. There was a significantly higher proportion of patients who reported subjective symptoms in females, those with a higher number of listed drug allergies, and those whose historical reactions were primarily subjective in nature. CONCLUSION: Drug challenges are safe procedures in appropriately selected patients. A number of patients report subjective symptoms during drug challenges. Identifying patients at high risk for subjective symptoms may assist in determining whether placebo-controlled drug challenges should be performed.

Development of a bedside tool to predict time to death after withdrawal of life-sustaining therapies in infants and children.

OBJECTIVES: To generate a preliminary bedside predictor of rapid time-to-death after withdrawal of support in children to help identify potential candidates for organ donation after circulatory death. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit of an academic children's hospital. PATIENTS: All deaths in the pediatric intensive care unit from May 1996 to April 2007. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 1389 deaths, 634 patients underwent withdrawal of support and 518 with complete data regarding demographics, life-supportive therapies, and end-of-life circumstances were analyzed. Three hundred seventy-three (72%) patients died within 30 mins of withdrawal and 452 (87%) died within 60 mins. Using multiple logistic regression, significant predictors of death within 30 or 60 mins (typical cut-off times for organ donation) were identified and a predictor score was generated. Significant predictors included: age 1 month or younger; norepinephrine, epinephrine, or phenylephrine >0.2 µg/kg/min; extracorporeal membrane oxygenation; and positive end-expiratory pressure >10 cmH2O; and spontaneous ventilation. Possible scores for the 30-min predictor ranged from -17 to 67; a score ≤-9 predicted a 37% probability of death ≤ 30 mins, whereas a score ≥ 38 predicted an 85% probability of death within 30 mins. For the 60-min predictor, scores ranged from -21 to 38; score ≤-10 predicted a 59% probability of death within 60 mins and a score ≥ 16 predicted a 98% probability of death within 60 mins. CONCLUSIONS: This tool is a reasonable preliminary predictor for death within 30 or 60 mins after withdrawal of support in terminally ill or injured children and might assist in identifying potential pediatric candidates for donation after circulatory death, although prospective validation is required.

Potential for liver and kidney donation after circulatory death in infants and children.

OBJECTIVE: To determine the potential effect of organ donation after circulatory death (DCD) on the number of kidney and liver donors in a PICU. PATIENTS AND METHODS: All deaths in the PICU of an academic, tertiary care children's hospital from May 1996 to April 2007 were retrospectively reviewed. Patient demographics, premortem physiology, and end-of-life circumstances were recorded and compared with basic criteria for potential organ donation. A sensitivity analysis was performed to examine the effect of more strict physiologic and time criteria as well as 3 different rates of consent for donation. RESULTS: There were 1389 deaths during 11 years; 634 children (46%) underwent withdrawal of life support, of whom 518 had complete data and were analyzed. There were 131 children (25% of those withdrawn, 9% of all deaths) who met basic physiologic and time criteria for organ donation (80 kidney; 107 liver). Consideration of consent rates in sensitivity analysis resulted in an estimated 24 to 85 organ donors, an increase of 28% to 99% over the 86 actual brain-dead donors during the same time period. Assuming historical rates of organ recovery, these DCD donors might have produced 30 to 88 additional kidneys and 8 to 56 additional livers, an increase of 21% to 60% in kidney donation and 13% to 80% in livers above the number of organs recovered from brain-dead donors. CONCLUSIONS: Although relatively few children may have been eligible for DCD, they might have increased the number of organ donors from our institution, depending greatly on consent rates. DCD merits additional discussion and exploration.

Health-related quality of life in children and adolescents with sickle cell disease.

OBJECTIVE: To assess health-related quality of life (HRQOL) in children and adolescents with sickle cell disease (SCD). DESIGN, SETTING, AND PARTICIPANTS: The PedsQL 4.0 Generic Scales, a multidimensional self-report instrument that has been shown to be valid and reliable for use in children and adolescents with chronic illness, consists of 23 items that assess physical, emotional, social, and school functioning. Questionnaires were administered to 124 children and adolescents (ages 8 to 18 years, child self-report) with SCD (100 sickle cell anemia, 24 sickle ß zero thalassemia) and their parents (parent-proxy report). Summary scores for children's and parents' ratings of overall HRQOL and psychosocial health and subscale scores for physical, emotional, social, and school functioning were compared with published data for healthy children. Both summary and subscale scores for children with SCD also were compared with those of their parents. RESULTS: Children with SCD and their parents rated overall HRQOL and all subdomains of HRQOL lower than did healthy children and their parents (P < .001). Children with SCD rated their own HRQOL significantly better than their parents did for overall HRQOL and all subdomains (P < .001) except emotional functioning (P = .06). CONCLUSIONS: Children with SCD and their parents perceived overall HRQOL and all HRQOL subdomains to be lower than scores reported in healthy children. Therefore, successful therapeutic efforts to improve HRQOL could represent important advances in the health of children with SCD.

Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries.

INTRODUCTION: Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful. MATERIALS AND METHODS: A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries. RESULTS: The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients. Patients with initial amylase and lipase levels measured greater than 2h post-injury were more consistently elevated compared to those patients who had levels measured at 2h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p=0.012). No significant association was found for lipase measurements (p=0.178). DISCUSSION AND CONCLUSIONS: In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2h post-injury compared to those measured at 2h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.

Differential recruitment of dendritic cells and monocytes to respiratory mucosal sites in children with influenza virus or respiratory syncytial virus infection.

BACKGROUND: Influenza virus and respiratory syncytial virus (RSV) are among the most common viruses causing infections of the lower respiratory tract in young children. Although there are important differences in the immunopathogenesis of these 2 viral pathogens, little is known about how they affect antigen-presenting cells in children with acute infections. METHODS: To characterize the immune cells that are mobilized to the respiratory tract by influenza virus and RSV, we analyzed nasal wash and blood samples obtained from children hospitalized with acute respiratory infections. RESULTS: Influenza virus and RSV mobilize immune cells, including myeloid dendritic cells (mDCs) and plasmacytoid dendritic cells (pDCs), to the nasal mucosa. Patients with influenza virus infection had greater numbers of mDCs, pDCs, and monocytes in nasal wash samples than did patients with RSV infection. The frequencies of respiratory tract and blood T cell subsets were not affected by infection with influenza virus or RSV. Monocyte chemoattractant protein-1 concentrations in nasal wash samples were significantly increased in patients with influenza virus infection but not in those with RSV infection. RANTES (regulated on activation, normally T cell expressed and secreted) concentrations were increased only in the blood of patients with influenza virus infection. CONCLUSIONS: Infection with influenza virus or RSV mobilizes antigen-presenting cells to the respiratory tract. The differences in antigen-presenting cell numbers and cytokine concentrations suggest that there are distinctive, early immune responses to these 2 viruses.

Effect of low-dose naloxone infusion on fentanyl requirements in critically ill children.

OBJECTIVE: Sedating critically ill patients often involves prolonged opioid infusions causing opioid tolerance. Naloxone has been hypothesized to limit opioid tolerance by decreasing adenylate cyclase/cyclic adenosine monophosphate activation. The study purpose was to investigate the effect of low-dose naloxone on the maximum cumulative daily fentanyl dose in critically ill children. METHODS: We conducted a double-blinded, randomized, placebo-control trial from December 2002 through July 2004 in a university PICU. We enrolled 82 children age 1 day to 18 years requiring mechanical ventilation and fentanyl infusions anticipated to last for >4 days were eligible for enrollment. Those receiving additional oral analgesia or sedation, having a history of drug dependence or withdrawal, or having significant neurologic, renal, or hepatic disease were excluded. In addition to fentanyl infusions, patients received low-dose naloxone or placebo infusions. Medications were adjusted using the Modified Motor Activity Assessment Scale. Withdrawal was monitored using the Modified Narcotic Withdrawal Scale. Intervention was a low-dose naloxone infusion (0.25 microg/kg per hour) and the main outcome variable was the maximum cumulative daily fentanyl dose (micrograms per kilogram per day). RESULTS: There was no difference in the maximum cumulative daily fentanyl dose between patients treated with naloxone (N = 37) or those receiving placebo (N = 35). Adjustment for the starting fentanyl dose also failed to reveal group differences. Total fentanyl dose received throughout the study in the naloxone group (360 microg/kg) versus placebo (223 microg/kg) was not statistically different. Placebo patients trended toward fewer rescue midazolam boluses (10.7 vs 17.8), lower total midazolam dose (11.6 mg/kg vs 23.9 mg/kg), and fewer rescue fentanyl boluses (18.5 vs 23.9). CONCLUSIONS: We conclude that administration of low-dose naloxone (0.25 microg/kg per hour) does not decrease fentanyl requirements in critically ill, mechanically ventilated children.

Low-dose ketamine: efficacy in pediatric sedation.

OBJECTIVES: Intravenous (IV) ketamine has gained widespread use in the emergency department (ED) for procedural sedation. The most commonly recommended starting dose is 1.5 mg/kg. We examined whether lower doses of ketamine in the range of 0.5 to 1.0 mg/kg could successfully sedate pediatric patients. METHODS: We retrospectively reviewed quality assurance data of patients sedated with IV ketamine in a pediatric ED. Patients were administered 0.02 mg/kg of IV atropine, 0.05 mg/kg of IV midazolam, and then 0.5 mg/kg of IV ketamine. Additional aliquots of 0.25 to 0.5 mg/kg of ketamine were given as necessary, to a maximum of 2.0 mg/kg. Efficacy of sedation was assessed after every dose by pediatric emergency medicine attendings or fellows. RESULTS: Seventy-two patients had quality assurance forms completed. The total ketamine dose administered ranged from 0.5 to 2 mg/kg. Adequate procedural sedation was obtained for 70 (97%) of 72 patients. Forty-four percent of patients required 0.75 mg/kg or less of ketamine to obtain adequate initial sedation; 25% of subjects required only 0.5 mg/kg; 43% of patients required 1.0 mg/kg of IV ketamine. We found that 88% of our patients could be successfully sedated at initial doses of 1 mg/kg or less. CONCLUSIONS: Our study suggests a potential role for low-dose IV ketamine in the range of 0.5 to 1.0 mg/kg for pediatric procedural sedation. Most pediatric ED patients can be successfully sedated with 1 mg/kg of ketamine.

Phosphorylated histone H3, Ki-67, p21, fatty acid synthase, and cleaved caspase-3 expression in benign and atypical granular cell tumors.

CONTEXT: Granular cell tumors (GCTs) are classified as benign when none of the following features is present: spindling of the tumor cells, necrosis, diffuse pleomorphism, prominent nucleoli, high nuclear-cytoplasmic ratio, and mitotic rate >2 per 10 high-power fields. It has been suggested that a GCT be classified as atypical when 1 or 2 of these features are seen and as malignant when 3 or more of these are present. In our practice, we do not classify GCTs as malignant in the absence of metastasis. OBJECTIVE: To compare immunohistochemical staining for phosphorylated histone H3 (PHH3), Ki-67 (MIB-1), p21, fatty acid synthase, and cleaved caspase-3 in histologically classified benign and atypical GCTs. DESIGN: We reviewed 25 cases of GCT from our archives and classified 14 as atypical based on histologic features. Immunohistochemical staining for PHH3, Ki-67, p21, fatty acid synthase, and cleaved caspase-3 was performed using standard methods. The number of positive cells for Ki-67, p21, and PHH3 was calculated in 10 consecutive high-power fields in a hot spot. Fatty acid synthase and cleaved caspase-3 cytoplasmic expression was graded from 1 to 3. RESULTS: Ki-67 and PHH3 scores were significantly higher in atypical GCTs. The expression of p21, fatty acid synthase, and cleaved caspase-3 was not significantly different between atypical and benign GCTs. CONCLUSIONS: This study shows that histologic features are reliable in identifying GCTs that have a higher proliferative potential as shown by higher immunoreactivity for Ki-67 and PHH3. These immunostains may help in classifying GCTs in cases where a thorough histologic evaluation is precluded by the small size of a biopsy specimen.

The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure.

OBJECTIVE: Midterm follow-up is analyzed after the aortic translocation (Nikaidoh) procedure, an alternative to the Rastelli procedure for ventriculoarterial discordance, ventricular septal defect, and pulmonary stenosis. METHODS: Nineteen patients underwent a Nikaidoh procedure at a median age of 3.3 years (0.9-9.3 years). The native aortic valve was translocated from the right to the left ventricular outflow tract by full (n = 6) or partial (n = 13) mobilization of the aortic root. Seven patients with partial mobilization had the right coronary artery reimplanted as a button. The conal septum was divided in 13 patients. The right ventricular outflow tract was reconstructed with either a homograft (n = 4) or a right ventricular outflow tract patch (n = 15). The median follow-up was 11.4 years (0.1-23 years), and the median age at follow-up was 17.4 years (1-30 years). Left ventricular outflow tract obstruction and aortic insufficiency were assessed by echocardiography. RESULTS: One patient died of right coronary arterial ischemia. All remaining patients (95%) survived. The median survival was 13.6 years (longest, 23.0 years). Seven right ventricular outflow tract reoperations were required in 5 patients (6 with obstruction and 1 with pulmonary insufficiency). No reoperations have been performed on the left ventricular outflow tract or aortic valve. No patient had any left ventricular outflow tract obstruction or aortic insufficiency more than mild (mild in 9 patients, trivial in 3 patients, and absent in 6 patients). CONCLUSIONS: Midterm actuarial survival was 95% after the Nikaidoh procedure. Reintervention for the right ventricular outflow tract is more common when valved conduits are used versus valveless reconstruction; however, the Nikaidoh procedure provides complete freedom from important aortic insufficiency and left ventricular outflow tract obstruction.

Reliability and validity of the Pediatric Intensity Level of Therapy (PILOT) scale: a measure of the use of intracranial pressure-directed therapies.

OBJECTIVE: To test the reliability and validity of the Pediatric Intensity Level of Therapy (PILOT) scale, a novel measure of overall therapeutic effort directed at controlling intracranial pressure (ICP) in the setting of severe (Glasgow Coma Scale of

Prevalence of spontaneous closure of the ductus arteriosus in neonates at a birth weight of 1000 grams or less.

OBJECTIVE: Ductus arteriosus (DA) closure occurs within 96 hours in >95% of neonates >1500 g in birth weight (BW). The prevalence and postnatal age of spontaneous ductal closure in neonates < or =1000 g in BW (extremely low birth weight [ELBW] neonates) remain unclear, as does the incidence of failure to close with indomethacin. Therefore, we prospectively examined the prevalence, postnatal age, and clinical variables associated with spontaneous DA closure, occurrence of persistent patent DA, and indomethacin failure in ELBW neonates. METHODS: Neonates delivered at Parkland Memorial Hospital from February 2001 through December 2003 were studied. Those with congenital heart defects or death <10 days postnatally were excluded. Echocardiograms were performed 48 to 72 hours postnatal and every 48 hours until 10 days postnatally. RESULTS: We studied 122 neonates with BW of 794 +/- 118 (SD) g and estimated gestational age (EGA) of 26 +/- 2 weeks. Spontaneous permanent DA closure occurred in 42 (34%) neonates at 4.3 +/- 2 days postnatally, with 100% closure by 8 days. These neonates were more mature, less likely to have received antenatal steroids or have hyaline membrane disease (HMD; 52% vs 79%), and more likely to be growth restricted (31% vs 5%) and delivered of hypertensive women. Using regression analysis, EGA and absence of antenatal steroids and HMD predicted ductal closure. Ten (8%) neonates with early DA closure reopened and required medical/surgical closure. Eighty neonates had persistent patent DA; 7 were surgically ligated, and 5 remained asymptomatic, with 4 of 5 closing after 10 days postnatally. Sixty-eight (85%) received indomethacin at 6.2 +/- 4 days postnatally; 41% failed therapy and had no distinguishing characteristics. CONCLUSIONS: Spontaneous permanent DA closure occurs in >34% of ELBW neonates and is predicted by variables related to maturation, for example, EGA and an absence of HMD, whereas indomethacin failure could not be predicated.