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1.
J Am Heart Assoc ; 9(7): e015318, 2020 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-32223393

RESUMO

Background Recent studies suggest that lymphatic congestion plays a role in development of late Fontan complications, such as protein-losing enteropathy. However, the role of the lymphatic circulation in early post-Fontan outcomes is not well defined. Methods and Results This was a retrospective, single-center study of patients undergoing first-time Fontan completion from 2012 to 2017. The primary outcome was early Fontan complication ≤6 months after surgery, a composite of death, Fontan takedown, extracorporeal membrane oxygenation, chest tube drainage >14 days, cardiac catheterization, readmission, or transplant. Complication causes were assigned to 1 of 4 groups: (1) Fontan circuit obstruction, (2) ventricular dysfunction or atrioventricular valve regurgitation, (3) persistent pleural effusions in the absence of Fontan obstruction or ventricular dysfunction, and (4) chylothorax or plastic bronchitis. T2-weighted magnetic resonance imaging sequences were used to assess for lymphatic perfusion abnormality. The cohort consisted of 238 patients. Fifty-eight (24%) developed early complications: 20 of 58 (34.5%) in group 1, 8 of 58 (14%) in group 2, 18 of 58 (31%) in group 3, and 12 of 58 (20%) in group 4. Preoperative T2 imaging was available for 126 (53%) patients. Patients with high-grade lymphatic abnormalities had 6 times greater odds of developing early complications (P=0.001). Conclusions There is substantial morbidity in the early post-Fontan period. Half of those who developed early complications had lymphatic failure or persistent effusions unrelated to structural or functional abnormalities. Preoperative T2 imaging demonstrated that patients with higher-grade lymphatic perfusion abnormalities were significantly more likely to develop early complications. This has implications for risk stratification and optimization of patients before Fontan palliation.

2.
Ann Thorac Surg ; 2020 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-32088289

RESUMO

BACKGROUND: Left atrioventricular valvar regurgitation (LAVVR) following atrioventricular canal (AVC) repair remains a significant cause of morbidity. Papillary muscle arrangement may be important. The implications of left mural leaflet morphology have not been investigated. We examined anatomic characteristics of the LAVV to determine possible associations with postoperative LAVVR. METHODS: All patients with biventricular AVC repair at our institution between 1/1/11 and 12/31/16 with necessary imaging were retrospectively reviewed. Papillary muscle structure and novel measures of the left mural leaflet were assessed from preoperative echocardiograms, and degree of LAVVR from the first and last available follow-up echocardiograms. Associations with degree of early and late postoperative LAVVR were assessed with t-tests, ANOVA or Chi-square/Fisher's exact tests, and multivariable logistic regression. RESULTS: Fifty-eight patients (37% of 156) had significant (moderate or severe) early postoperative LAVVR. Thirty (32% of 93) had significant LAVVR after 6 or more months. Fewer patients with closely-spaced or asymmetric papillary muscles had moderate or severe late LAVVR versus those with widely-spaced papillary muscles (17% versus 40%, P=0.019). Controlling for weight at surgery, genetic syndromes and bypass time, widely-spaced papillary muscles increased the odds ratio for late LAVVR to 3.6 (P=0.026). Larger mural leaflet area was also associated with late LAVVR on univariable and multivariable analyses (P=0.019; P=0.023). A third of patients with significant late LAVVR had no significant early postoperative regurgitation. CONCLUSIONS: Mural leaflet and papillary muscle anatomy are associated with late LAVVR after AVC repair. Late regurgitation can develop in the absence of early LAVVR, suggesting different mechanisms.

3.
Acad Pediatr ; 2020 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-32081765

RESUMO

OBJECTIVE: To determine the association between neighborhood poverty and ADHD severity among children in a large metropolitan area. METHODS: This is a secondary analysis of data collected April 2016 to July 2017 at the Children's Hospital of Philadelphia Care Network. We attributed 2015 American Community Survey census tract poverty, defined as percent of individuals with income below poverty level, to each child's residential address. Tracts were grouped from low to high poverty. ADHD severity was determined by Vanderbilt Parent Rating Scale (VPRS) symptom score. We also recorded parent-reported child ADHD medication use. RESULTS: A total of 286 children were linked to 203 unique census tracts. The majority of children from high poverty tracts were black and from disadvantaged households. Higher neighborhood poverty was associated with higher VPRS scores and decreased medication use in bivariate analysis. Poverty was no longer associated with VPRS scores in multivariate analysis, but medication use still had a significant negative association with VPRS score. Post-hoc stratification by medication use revealed that neighborhood poverty and VPRS score were significantly associated for children on medication, but not for those off medication. CONCLUSIONS: Neighborhood poverty was not associated with ADHD severity in multivariate analysis. This suggests other factors, including medication use, confound the relationship between neighborhood poverty and ADHD severity. Lack of medication treatment was significantly associated with higher symptom burdens for children with access to primary care. Decreased medication use in higher poverty communities warrants exploration and public health interventions to ensure adequate ADHD management for all children.

4.
Clin Pediatr (Phila) ; 59(3): 228-235, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31893928

RESUMO

Pediatric systemic hypertension (HTN) is underdiagnosed and undertreated. The Divisions of Cardiology and Nephrology at our institution developed a comprehensive outpatient HTN program to (1) screen children at risk for HTN, (2) assess cardiovascular health, and (3) optimize medical management. We report our findings during all initial visits (n = 304) from December 2011 to September 2018. Of the cohort, 38% were obese and 36% reported little to no exercise. More than half of patients ≥11 years old did not have recommended lipid screening. When evaluating ambulatory blood pressure monitoring results, clinic blood pressure did not accurately diagnose patients with or without HTN and many patients on antihypertensive medications were inadequately treated. Visit recommendations included addition of or changes to antihypertensive medication in 35% of patients. A multidisciplinary program dedicated to pediatric HTN helps screen patients who are at risk. Ambulatory blood pressure monitoring identifies HTN in patients with normal clinic blood pressure and those on antihypertensive medication.

5.
Acad Pediatr ; 20(1): 81-88, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31376579

RESUMO

OBJECTIVE: Pediatric residents are expected to be competent in end-of-life (EOL) care. We aimed to quantify pediatric resident exposure to patient deaths, and the context of these exposures. METHODS: Retrospective chart review of all deceased patients at one children's hospital over 3 years collected patient demographics, time, and location of death. Mode of death was determined after chart review. Each death was cross-referenced with pediatric resident call schedules to determine residents involved within 48 hours of death. Descriptive statistics are presented. RESULTS: Of 579 patients who died during the study period, 46% had resident involvement. Most deaths occurred in the NICU (30% of all deaths); however, resident exposure to EOL care most commonly occurred in the PICU (52% of resident exposures) and were after withdrawals of life-sustaining therapy (41%), followed by nonescalation (31%) and failed resuscitation (15%). During their postgraduate year (PGY)-1, <1% of residents encountered a patient death. During PGY-2 and PGY-3, 96% and 78%, respectively, of residents encountered at least 1 death. During PGY-2, residents encountered a mean of 3.5 patient deaths (range 0-12); during PGY-3, residents encountered a mean of 1.4 deaths (range 0-5). Residents observed for their full 3-year residency encountered a mean of 5.6 deaths (range 2-10). CONCLUSIONS: Pediatric residents have limited but variable exposure to EOL care, with most exposures in the ICU after withdrawal of life-sustaining technology. Educators should consider how to optimize EOL education with limited clinical exposure, and design resident support and education with these variable exposures in mind.

6.
Resuscitation ; 146: 56-63, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31734222

RESUMO

INTRODUCTION: Survival after in-hospital cardiac arrest (IHCA) has been reported to be worse for arrests at night or during weekends.This study aimed to determine whether measured cardiopulmonary resuscitation (CPR) quality metrics might explain this difference in outcomes. METHODS: IHCA data was collected by the Pediatric Resuscitation Quality (pediRES-Q) collaborative for patients <18 years. Metrics of CPR quality [chest compression rate, depth and fraction] were measured using monitordefibrillator pads, and events were compared by time of day and day of week. RESULTS: We evaluated 6915 sixty-second epochs of chest compression (CC) data from 239 subjects between October 2015 and March 2019, across 18 hospitals. There was no significant difference in CPR quality metrics during day (07:00-22:59) versus night (23:00-06:59), or weekdays (Monday 07:00 to Friday 22:59) versus weekends (Friday 23:00 to Monday 06:59).There was also no difference in rate of return of circulation. However, survival to hospital discharge was higher for arrests that occurred during the day (39.1%) vs. nights (22.4%, p = 0.015), as well as on weekdays (39.9%) vs. weekends (19.1%, p = 0.003). CONCLUSIONS: For pediatric IHCA where CC metrics were obtained, there was no significant difference in CPR quality metrics or rate of return of circulation by time of day or day of week. There was higher survival to hospital discharge when arrests occurred during the day (vs. nights), or on weekdays (vs. weekends), and this difference was not related to disparities in CC quality.

7.
J Am Heart Assoc ; 8(14): e012637, 2019 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-31288613

RESUMO

Background Whether racial and neighborhood characteristics are associated with bystander cardiopulmonary resuscitation ( BCPR ) in pediatric out-of-hospital cardiac arrest ( OHCA ) is unknown. Methods and Results An analysis was conducted of CARES (Cardiac Arrest Registry to Enhance Survival) for pediatric nontraumatic OHCA s from 2013 to 2017. An index (range, 0-4) was created for each arrest based on neighborhood characteristics associated with low BCPR (>80% black; >10% unemployment; <80% high school; median income, <$50 000). The primary outcome was BCPR . BCPR occurred in 3399 of 7086 OHCA s (48%). Compared with white children, BCPR was less likely in other races/ethnicities (black: adjusted odds ratio [ aOR ], 0.59; 95% CI , 0.52-0.68; Hispanic: aOR , 0.78; 95% CI , 0.66-0.94; and other: aOR , 0.54; 95% CI , 0.40-0.72). Compared with arrests in neighborhoods with an index score of 0, BCPR occurred less commonly for arrests with an index score of 1 ( aOR , 0.80; 95% CI , 0.70-0.91), 2 ( aOR , 0.75; 95% CI , 0.65-0.86), 3 ( aOR , 0.52; 95% CI , 0.45-0.61), and 4 ( aOR , 0.46; 95% CI , 0.36-0.59). Black children had an incrementally lower likelihood of BCPR with increasing index score while white children had an overall similar likelihood at most scores. Black children with an index of 4 were approximately half as likely to receive BCPR compared with white children with a score of 0. Conclusions Racial and neighborhood characteristics are associated with BCPR in pediatric OHCA . Targeted CPR training for nonwhite, low-education, and low-income neighborhoods may increase BCPR and improve pediatric OHCA outcomes.

8.
J Am Coll Radiol ; 16(12): 1636-1644, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31092342

RESUMO

OBJECTIVE: To describe imaging utilization, outcomes, and cost in the management of intussusception between 2010 and 2017 in pediatric hospitals in the United States. METHODS: All children (under 18 years of age) with a primary diagnosis of intussusception in a large administrative database were identified. Demographics, imaging, and costs were described. RESULTS: There were 17,032 children (63.3% boys, 36.7% girls, mean age: 3.2 years) that had 20,655 hospital encounters for intussusception, and 88.5% were <5 years of age. The average length of stay was 2.8 days (median: 1 day), with rates of intensive care unit admission, 3.7%; 90-day readmission, 10.5%; and mortality, 0.2%. The surgical rate was 19.6%, and 93.5% (n = 19,301) of patients underwent imaging: 87.2% (n = 16,822) received ultrasound, 69.1% (n = 13,329) had fluoroscopy, 59% (n = 11,380) had abdominal radiographs, and 8.8% (n = 1,696) had CT. The reduction success rate for fluoroscopy was 77.9%. Surgery was more common in rural patients (26.8% versus 18.7% in urban patients, P < .001). Median encounter costs were $2,675 (interquartile range: $1,637-$5,465). Imaging cost represented a quarter (median $680, interquartile range: $372-1,069) of all costs. Higher costs (median) were associated with longer length of stay (<3 days: $858 versus >3 days: $5,342; use of CT ($4,168 versus $943 in patients without a CT), and surgery ($4,434 versus $860 without surgery). CONCLUSION: The management of intussusception is mainly nonsurgical, most frequently involving imaging with ultrasound and fluoroscopy, and resulting in excellent outcomes in the great majority of the cases. Despite playing a central role for diagnosis and management, imaging only represents a fraction of total cost.

9.
Pediatr Cardiol ; 40(5): 1057-1063, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31065759

RESUMO

In complete atrioventricular canal defect (CAVC), there are limited data on preoperative clinical and echocardiographic predictors of operative timing and postoperative outcomes. A retrospective, single-center analysis of all patients who underwent primary biventricular repair of CAVC between 2006 and 2015 was performed. Associated cardiac anomalies (tetralogy of Fallot, double outlet right ventricle) and arch operation were excluded. Echocardiographic findings on first postnatal echocardiogram were correlated with surgical timing and postoperative outcomes using bivariate descriptive statistics and multivariable logistic regression. 153 subjects (40% male, 84% Down syndrome) underwent primary CAVC repair at a median age of 3.3 (IQR 2.5-4.2) months. Median postoperative length of stay (LOS) was 7 (IQR 5-15) days. Eight patients (5%) died postoperatively and 24 (16%) required reoperation within 1 year. On multivariable analysis, small aortic isthmus (z score < - 2) was associated with early primary repair at < 3 months (OR 2.75, 95% CI 1.283-5.91) and need for early reoperation (OR 3.79, 95% CI 1.27-11.34). Preoperative ventricular dysfunction was associated with higher postoperative mortality (OR 7.71, 95% CI 1.76-33.69). Other factors associated with mortality and longer postoperative LOS were prematurity (OR 5.30, 95% CI 1.24-22.47 and OR 5.50, 95% CI 2.07-14.59, respectively) and lower weight at surgery (OR 0.17, 95% CI 0.04-0.75 and OR 0.55, 95% CI 0.35-0.85, respectively). Notably, preoperative atrioventricular valve regurgitation and Down syndrome were not associated with surgical timing, postoperative outcomes or reoperation, and there were no echocardiographic characteristics associated with late reoperation beyond 1 year after repair. Key preoperative echocardiographic parameters helped predict operative timing and postoperative outcomes in infants undergoing primary CAVC repair. Aortic isthmus z score < - 2  was associated with early surgical repair and need for reoperation, while preoperative ventricular dysfunction was associated with increased mortality. These echocardiographic findings may help risk-stratified patients undergoing CAVC repair and improve preoperative counseling and surgical planning.


Assuntos
Defeitos dos Septos Cardíacos/cirurgia , Tempo para o Tratamento , Síndrome de Down/complicações , Ecocardiografia , Feminino , Defeitos dos Septos Cardíacos/diagnóstico por imagem , Humanos , Lactente , Recém-Nascido Prematuro , Masculino , Reoperação , Estudos Retrospectivos , Resultado do Tratamento
10.
Am J Crit Care ; 28(3): 174-181, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31043397

RESUMO

BACKGROUND: Transthoracic intracardiac catheters are central catheters placed in the operating room at the conclusion of cardiac surgery for infants and children. Complications associated with these catheters (eg, bleeding, migration, premature removal, infection, leakage, and lack of function) have been described. However, no researchers have addressed the nursing management of these catheters in the intensive care unit, including catheter dressing and securement, mobilization of patients, and flushing the catheters, or the impact of these interventions on patients' outcomes. OBJECTIVES: To internationally benchmark current nursing practice associated with care of infants and children with transthoracic intracardiac catheters. METHODS: In a cross-sectional, descriptive study of nursing practice in infants and children with transthoracic intracardiac catheters, a convenience sample of bedside and advanced practice nurses was recruited to complete an online survey to benchmark current practice. The survey included questions on criteria for catheter insertion and removal, dressing care, flushing practice, securement, and mobilization of patients. RESULTS: Transthoracic intracardiac catheters are used by most centers that provide care for infants and children after open heart surgery. A wide range of practices was reported. CONCLUSIONS: Standardizing the use and care of transthoracic intracardiac catheters can improve the safety and efficacy of their use in infants and children and promote safe and early postoperative mobilization of patients.

11.
Radiology ; 291(3): 774-780, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30938628

RESUMO

Background The Fontan operation is performed for surgical palliation of single ventricle physiology. This operation is usually preceded by a superior cavopulmonary connection (SCPC); lymphatic abnormalities after SCPC may be demonstrated at MRI and prior to the Fontan operation. Purpose To determine if the degree of neck and thoracic lymphatic abnormalities at T2-weighted MRI in patients after superior cavopulmonary connection (SCPC) correlated with surgical outcomes from the Fontan procedure. Materials and Methods Patients for whom SCPC was performed for palliation of single ventricle disease who underwent chest MRI between July 2012 and May 2015 at a single institution were retrospectively reviewed. T2-weighted images were scored as lymphatic type 1 (little or no T2 mediastinal and supraclavicular signal) to type 4 (T2 signal into both the mediastinum and the lung parenchyma). Fontan takedown, duration of post-Fontan hospitalization and pleural effusion, postoperative plastic bronchitis, need for transplant, and mortality were tabulated. The relationship between lymphatic type and clinical outcomes was evaluated by using analysis of variance (ANOVA), the Kruskal-Wallis H test, and the Fisher exact test. Results A total of 83 patients (mean age, 7.9 years ± 2.6) were evaluated. Among these 83 patients, 53 (64%) were classified with type 1 or 2 lymphatic abnormalities, 17 (20%) with type 3, and 12 (16%) with type 4. The rate of failure of Fontan completion was higher in patients with type 4 than in type 1 or 2 (54% vs 2%, respectively; P = .004). Need for cardiac transplant (one of 13 [8%]) and death (three of 13 [23%]) occurred only in type 4. Median postoperative length of stay was longer for patients with type 4 than for those with types 1 or 2 (29 days vs 9 days, respectively; P < .01). Conclusion Greater MRI-based severity of lymphatic abnormalities in patients prior to planned Fontan procedure was associated with failure of Fontan completion and longer postoperative stay. © RSNA, 2019 Online supplemental material is available for this article.


Assuntos
Técnica de Fontan , Anormalidades Linfáticas/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Criança , Pré-Escolar , Técnica de Fontan/efeitos adversos , Técnica de Fontan/mortalidade , Técnica de Fontan/estatística & dados numéricos , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/cirurgia , Humanos , Tempo de Internação , Anormalidades Linfáticas/etiologia , Sistema Linfático/diagnóstico por imagem , Sistema Linfático/patologia , Imagem por Ressonância Magnética , Pescoço/diagnóstico por imagem , Pescoço/patologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Tórax/diagnóstico por imagem , Tórax/patologia , Resultado do Tratamento
12.
J Pain Symptom Manage ; 58(1): 11-18, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31004773

RESUMO

CONTEXT: Interprofessional teams often develop a care plan before engaging in a family meeting in the pediatric cardiac intensive care unit (CICU)-a process that can affect the course of the family meeting and alter team dynamics but that has not been studied. OBJECTIVES: To characterize the types of interactions that interprofessional team members have in pre-family meeting huddles in the pediatric CICU by 1) evaluating the amount of time each team member speaks; 2) assessing team communication and teamwork using standardized instruments; and 3) measuring team members' perceptions of collaboration and satisfaction with decision making. METHODS: We conducted a prospective observational study in a pediatric CICU. Subjects were members of the interprofessional team attending preparation meetings before care meetings with families of patients admitted to the CICU for longer than two weeks. We quantitatively coded the amount each team member spoke. We assessed team performance of communication and teamwork using the PACT-Novice tool, and we measured perception of collaboration and satisfaction with decision making using the Collaboration and Satisfaction About Care Decisions questionnaire. RESULTS: Physicians spoke for an average of 83.9% of each meeting's duration (SD 7.5%); nonphysicians averaged 9.9% (SD 5.2%). Teamwork behaviors were present and adequately performed as judged by trained observers. Significant differences in physician and nonphysician perceptions of collaboration were found in three of 10 observed meetings. CONCLUSION: Interprofessional team members' interactions in team meetings provide important information about team dynamics, revealing potential opportunities for improved collaboration and communication in team meetings and subsequent family meetings.

13.
Circ Cardiovasc Interv ; 12(4): e007232, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30998390

RESUMO

BACKGROUND: In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown. METHODS AND RESULTS: Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all). CONCLUSIONS: In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.

14.
J Health Care Poor Underserved ; 30(1): 265-279, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30827982

RESUMO

Families' access to local food-insecurity (FI) resources differs. This study examines how health system and public data may be combined to identify limitations in community resources designed to address FI. We conducted a retrospective cohort study using electronic health record (EHR) data from nine practices that screened families for FI. Electronic health record data included demographic and clinical characteristics. Publicly available data included local socioeconomic and food resource information. We calculated the distance from each household to the nearest food pantry and determined the percentage of families who might have difficulty accessing resources. We demonstrate how health systems could merge these data sources to map where food-insecure families live, describe families' access to local resources, and identify regions where gaps in services exist. Health systems could use this approach to support households with FI and advocate for additional services in areas lacking resources in order to target population health efforts.


Assuntos
Família , Assistência Alimentar/estatística & dados numéricos , Abastecimento de Alimentos , Pré-Escolar , Registros Eletrônicos de Saúde , Feminino , Sistemas de Informação Geográfica , Hospitais Pediátricos , Humanos , Lactente , Masculino , Programas de Rastreamento , Philadelphia , Estudos Retrospectivos
15.
J Dev Behav Pediatr ; 40(3): 170-175, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30907771

RESUMO

OBJECTIVE: The primary objective of this study was to describe analgesia administration between neurotypical (NT) individuals and those with autism spectrum disorder (ASD) diagnosed with appendicitis or long bone fractures in the emergency department (ED). A secondary objective was to compare the rates of complicated appendicitis as a proxy for delayed diagnosis between the groups. METHODS: This is a retrospective cohort study using the Pediatric Health Information System database. Study participants were children aged 6 to 18 years with ASD and with an ED visit for appendicitis or fracture between 2004 and 2015 who were matched to demographically similar NT children. Children with a developmental disorder and/or complex chronic condition were excluded. Coarsened exact matching and logistic regression were used to investigate the association between ASD status and opioid and non-opioid medication receipt. Comparison of the rates of complicated appendicitis in children with ASD and NT children was conducted before matching. RESULTS: From 2004 to 2015, 126,412 children with appendicitis and 392,151 children with long bone fractures were identified. Of these, 889 children had a diagnosis of ASD and were matched to 35,672 NT controls with appendicitis. In addition, 2117 children with ASD were matched to 200,635 NT controls with long bone fractures. Receipt of opioids or nonsteroidal anti-inflammatory drugs was not found to be significantly different between the 2 groups. However, a larger proportion of children with ASD presented with complicated appendicitis compared with NT controls (37.1% vs 29.9%, respectively; p < 0.001). CONCLUSION: Receipt of analgesia did not differ significantly between populations of ASD and NT peers. Children with ASD have increased rates of complex appendicitis, possibly suggesting limited access to care or provider difficulty in evaluating this patient population.

16.
J Asthma ; 56(1): 95-103, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29437489

RESUMO

OBJECTIVE: To assess the feasibility of a mobile health, inhaled corticosteroid (ICS) adherence reminder intervention and to characterize adherence trajectories immediately following severe asthma exacerbation in high-risk urban children with persistent asthma. METHODS: Children aged 2-13 with persistent asthma were enrolled in this pilot randomized controlled trial during an asthma emergency department (ED) visit or hospitalization. Intervention arm participants received daily text message reminders for 30 days, and both arms received electronic sensors to measure ICS use. Primary outcomes were feasibility of sensor use and text message acceptability. Secondary outcomes included adherence to prescribed ICS regimen and 30-day adherence trajectories. Group-based trajectory modeling was used to examine adherence trajectories. RESULTS: Forty-one participants (mean age 5.9) were randomized to intervention (n = 21) or control (n = 20). Overall, 85% were Black, 88% had public insurance, and 51% of the caregivers had a high school education or less. Thirty-two participant families (78%) transmitted medication adherence data; of caregivers who completed the acceptability survey, 25 (96%) chose to receive daily reminders beyond that study interval. Secondary outcome analyses demonstrated similar average daily adherence between groups (intervention = 36%; control = 32%, P = 0.73). Three adherence trajectories were identified with none ever exceeding 80% adherence. CONCLUSIONS: Within a high-risk pediatric cohort, electronic monitoring of ICS use and adherence reminders delivered via text message were feasible for most participants, but there was no signal of effect. Adherence trajectories following severe exacerbation were suboptimal, demonstrating an important opportunity for asthma care improvement.


Assuntos
Corticosteroides/uso terapêutico , Asma/tratamento farmacológico , Broncodilatadores/uso terapêutico , Adesão à Medicação/estatística & dados numéricos , Sistemas de Alerta , Tecnologia de Sensoriamento Remoto/métodos , Mensagem de Texto , Administração por Inalação , Corticosteroides/administração & dosagem , Broncodilatadores/administração & dosagem , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Masculino , Cooperação do Paciente , Preferência do Paciente , Projetos Piloto , Índice de Gravidade de Doença , Fatores Socioeconômicos
17.
J Am Heart Assoc ; 7(24): e009860, 2018 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-30561251

RESUMO

Background Over 6000 children have an in-hospital cardiac arrest in the United States annually. Most will not survive to discharge, with significant variability in survival across hospitals suggesting improvement in resuscitation performance can save lives. Methods and Results A prospective observational study of quality of chest compressions ( CC ) during pediatric in-hospital cardiac arrest associated with development and implementation of a resuscitation quality bundle. Objectives were to: 1) implement a debriefing program, 2) identify impediments to delivering high quality CC , 3) develop a resuscitation quality bundle, and 4) measure the impact of the resuscitation quality bundle on compliance with American Heart Association ( AHA ) Pediatric Advanced Life Support CC guidelines over time. Logistic regression was used to assess the relationship between compliance and year of event, adjusting for age and weight. Over 3 years, 317 consecutive cardiac arrests were debriefed, 38% (119/317) had CC data captured via defibrillator-based accelerometer pads, data capture increasing over time: (2013:13% [12/92] versus 2014:43% [44/102] versus 2015:51% [63/123], P<0.001). There were 2135 1-minute cardiopulmonary resuscitation (CPR) epoch data available for analysis, (2013:152 versus 2014:922 versus 2015:1061, P<0.001). Performance mitigating themes were identified and evolved into the resuscitation quality bundle entitled CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefing and Simulation (CODE ACES2). The adjusted marginal probability of a CC epoch meeting the criteria for excellent CPR (compliant for rate, depth, and chest compression fraction) in 2015, after CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefing and Simulation was developed and implemented, was 44.3% (35.3-53.3) versus 19.9%(6.9-32.9) in 2013; (odds ratio 3.2 [95% confidence interval:1.3-8.1], P=0.01). Conclusions CODE ACES2 was associated with progressively increased compliance with AHA CPR guidelines during in-hospital cardiac arrest.


Assuntos
Reanimação Cardiopulmonar/normas , Parada Cardíaca/terapia , Pacotes de Assistência ao Paciente/normas , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Fidelidade a Diretrizes/normas , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Pacientes Internados , Masculino , Guias de Prática Clínica como Assunto/normas , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Fluxo de Trabalho , Adulto Jovem
18.
Circulation ; 138(19): 2119-2129, 2018 11 06.
Artigo em Inglês | MEDLINE | ID: mdl-30474422

RESUMO

BACKGROUND: The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. METHODS: A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models. RESULTS: Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest. CONCLUSIONS: There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.


Assuntos
Transposição das Grandes Artérias , Disparidades em Assistência à Saúde , Padrões de Prática Médica , Cuidados Pré-Operatórios , Transposição dos Grandes Vasos/cirurgia , Transposição das Grandes Artérias/efeitos adversos , Transposição das Grandes Artérias/economia , Transposição das Grandes Artérias/mortalidade , Cateterismo Cardíaco , Fármacos Cardiovasculares/administração & dosagem , Bases de Dados Factuais , Feminino , Disparidades em Assistência à Saúde/economia , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Recém-Nascido , Tempo de Internação , Masculino , Padrões de Prática Médica/economia , Cuidados Pré-Operatórios/efeitos adversos , Cuidados Pré-Operatórios/economia , Cuidados Pré-Operatórios/mortalidade , Prostaglandinas/administração & dosagem , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento , Transposição dos Grandes Vasos/economia , Transposição dos Grandes Vasos/mortalidade , Transposição dos Grandes Vasos/fisiopatologia , Resultado do Tratamento
19.
J Am Coll Cardiol ; 72(15): 1817-1825, 2018 10 09.
Artigo em Inglês | MEDLINE | ID: mdl-30286926

RESUMO

BACKGROUND: Data related to the epidemiology and resource utilization of congenital heart disease (CHD)-related emergency department (ED) visits in the pediatric population is limited. OBJECTIVES: The purpose of this analysis was to describe national estimates of pediatric CHD-related ED visits and evaluate medical complexity, admissions, resource utilization, and mortality. METHODS: This was an epidemiological analysis of ED visit-level data from the 2006 to 2014 Nationwide Emergency Department Sample. Patients age <18 years with CHD were identified using International Classification of Diseases-9th Revision-Clinical Modification codes. We evaluated time trends using weighted regression and tested the hypothesis that medical complexity, resource utilization, and mortality are higher in CHD patients. RESULTS: A total of 420,452 CHD-related ED visits (95% confidence interval [CI]: 416,897 to 422,443 visits) were identified, accounting for 0.17% of all pediatric ED visits. Those with CHD were more likely to be <1 year of age (43% vs. 13%), and to have ≥1 complex chronic condition (35% vs. 2%). CHD-related ED visits had higher rates of inpatient admission (46% vs. 4%; adjusted odds ratio: 1.89; 95% CI: 1.85 to 1.93), higher median ED charges ($1,266 [interquartile range (IQR): $701 to $2,093] vs. $741 [IQR: $401 to $1,332]), and a higher mortality rate (1% vs. 0.04%; adjusted odds ratio: 1.25; 95% CI: 1.07 to 1.45). Adjusted median charges for CHD-related ED visits increased from $1,219 (IQR: $673 to $2,138) to $1,630 (IQR: $901 to $2,799), while the mortality rate decreased from 1.13% (95% CI: 0.71% to 1.52%) to 0.75% (95% CI: 0.41% to 1.09%) over the 9 years studied. CONCLUSIONS: Children with CHD presenting to the ED represent a medically complex population at increased risk for morbidity, mortality, and resource utilization compared with those without CHD. Over 9 years, charges increased, but the mortality rate improved.


Assuntos
Serviços de Saúde da Criança , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Cardiopatias Congênitas , Adolescente , Criança , Serviços de Saúde da Criança/economia , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Comorbidade , Serviços Médicos de Emergência/economia , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/tendências , Feminino , Recursos em Saúde/estatística & dados numéricos , Cardiopatias Congênitas/epidemiologia , Cardiopatias Congênitas/terapia , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Masculino , Estados Unidos/epidemiologia , Revisão da Utilização de Recursos de Saúde/estatística & dados numéricos
20.
Am J Public Health ; 108(10): 1330-1333, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30138064

RESUMO

As the most accurate reflection of the United States population, the US decennial census is vital to health policymakers and others at all levels of government. Competing priorities related to cost containment and the introduction of new reforms raise concerns about the resources available to the US Census Bureau to conduct an accurate population enumeration in 2020. We examined the state of the Census Bureau's preparations for the 2020 Census and how inaccuracies in the coming census enumeration could influence public health and health equity in the coming decade. The results of the 2020 Census will be used to allocate trillions of dollars in federal funding to states, including support for programs vital to public health such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children. Inaccuracies in the census enumeration could create a misalignment between states' needs and allocation of federal resources. Also, a census miscount of the population could create challenges for public health surveillance and research activities that inform public health policies and interventions.


Assuntos
Censos , Necessidades e Demandas de Serviços de Saúde , Saúde Pública , Política Pública , Demografia , Humanos , Estados Unidos
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