Faster discharge with lactated ringers than normal saline in first 72 h of acute pancreatitis: A multicenter randomized trial.

OBJECTIVES: Data driven strategies for acute pancreatitis (AP) in pediatrics are limited; adult data suggests lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes, but has not been studied in pediatrics. Our objective was to evaluate the efficacy of LR during the first 48 h of an AP episode compared with NS. STUDY DESIGN: A multisite randomized controlled clinical trial, from 2015 to 2020 (Clinical Trials.gov NCT03242473). Patients were randomized to exclusively LR or NS for the first 48 h. Primary outcomes were serial C-reactive protein (CRP) values. Secondary outcomes included other lab values, time to feeds, length of stay (LOS), systemic inflammatory response syndrome (SIRS) development, and progression to severe AP (SAP). RESULTS: We studied 76 patients (38 LR, 38 NS). CRP at 24 and 48 h were not significantly different between LR or NS group. Additionally, there were no differences in trends of BUN, amylase, lipase, SIRS status, or SAP development between the LR and NS group at 24 and 48 h. A higher proportion of LR patients (32%, 12/38) were discharged before 48 h compared to NS (13%, 5/38). The LR group had a significantly higher rate of discharge within the first 72 h compared to the NS group (p = 0.02). CONCLUSION: The use of LR was associated with a faster rate of discharge during the intervention period and in the first 72 h, but no other differences compared to NS. This reduction in length of hospitalization has significant implications for patients and healthcare costs.

Who's at Risk? A Prognostic Model for Severity Prediction in Pediatric Acute Pancreatitis.

OBJECTIVES: The aim of the study was to validate and optimize a severity prediction model for acute pancreatitis (AP) and to examine blood urea nitrogen (BUN) level changes from admission as a severity predictor. STUDY DESIGN: Patients from 2 hospitals were included for the validation model (Children's Hospital of the King's Daughters and Children's National Hospital). Children's Hospital of the King's Daughters and Cincinnati Children's Hospital Medical Center data were used for analysis of BUN at 24 to 48 hours. RESULTS: The validation cohort included 73 patients; 22 (30%) with either severe or moderately severe AP, combined into the all severe AP (SAP) group. Patients with SAP had higher BUN (P = 0.002) and lower albumin (P = 0.005). Admission BUN was confirmed as a significant predictor (P = 0.005) of SAP (area under the receiver operating characteristic [AUROC] 0.73, 95% confidence interval [CI] 0.60-0.86). Combining BUN (P = 0.005) and albumin (P = 0.004) resulted in better prediction for SAP (AUROC 0.83, 95% CI 0.72-0.94). A total of 176 AP patients were analyzed at 24-48 hours; 39 (22%) met criteria for SAP. Patients who developed SAP had a significantly higher BUN (P < 0.001) after 24 hours. Elevated BUN levels within 24 to 48 hours were independently predictive of developing SAP (AUROC: 0.76, 95% CI: 0.66-0.85). Patients who developed SAP had a significantly smaller percentage decrease in BUN from admission to 24 to 48 hours (P = 0.002). CONCLUSION: We externally validated the prior model with admission BUN levels and further optimized it by incorporating albumin. We also found that persistent elevation of BUN is associated with development of SAP. Our model can be used to risk stratify patients with AP on admission and again at 24 to 48 hours.

Utility of the DIVA score for experienced emergency department technicians.

BACKGROUND: The DIVA score is validated for predicting success of the initial attempt at peripheral intravenous insertion by nurses and physicians. A score of 4 or greater is 50% to 60% likely to have a failed first attempt. The study objective was to assess the validity of this score for emergency department technicians. METHODS: This study used a prospective convenience sample of 181 children presenting to the emergency department with intravenous access attempt by one of 29 emergency department technicians. DIVA score, total number of attempts, and median time to successful intravenous cannulation were obtained. RESULTS: Comparing patients with a DIVA score <4 to ≥4, first-time IV placement failure rates were lower (9% [95% CI, 3-24] vs. 41% [95% CI, 33-49]) and median time to IV placement was shorter (75 [interquartile range (IQR) 42-157] vs. 254 [IQR 91-806]) seconds. In patients with scores ≥4, emergency department technicians with ≥5 years of experience were significantly more likely to be successful on the first attempt (OR 2.8; 95% CI, 1.03-7.63). For every year of technician experience, the time to catheter placement, adjusted for DIVA score, decreased by 25 minutes (P≤0.05, R2=0.05). Comparing our receiver operating curve to the derivation study, the areas were similar (0.67 vs. 0.65). CONCLUSIONS: This study provides preliminary evidence for the validity of the DIVA score when applied to IVs placed by emergency department technicians. For patients with high DIVA scores, ≥5 years of IV experience was associated with higher odds of successful first-time IV placement and shorter time to placement. HIGHLIGHTS The difficult intravenous access (DIVA) score may be generalizable to IVs placed by experienced emergency department technicians (EDTs) Higher odds of first-time success in difficult patients with ≥5 years EDT experience Early identification of difficult access may allow for aid of alternative technology Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.

Reliability of muscle blood flow and oxygen consumption response from exercise using near-infrared spectroscopy.

NEW FINDINGS: What is the central question of this study? Continuous-wave near-infrared spectroscopy, coupled with venous and arterial occlusions, offers an economical, non-invasive alternative to measuring skeletal muscle blood flow and oxygen consumption, but its reliability during exercise has not been established. What is the main finding and its importance? Continuous-wave near-infrared spectroscopy devices can reliably assess local skeletal muscle blood flow and oxygen consumption from the vastus lateralis in healthy, physically active adults. The patterns of response exhibited during exercise of varying intensity agree with other published results using similar methodologies, meriting potential applications in clinical diagnosis and therapeutic assessment. Near-infrared spectroscopy (NIRS), coupled with rapid venous and arterial occlusions, can be used for the non-invasive estimation of resting local skeletal muscle blood flow (mBF) and oxygen consumption (mV̇O2), respectively. However, the day-to-day reliability of mBF and mV̇O2 responses to stressors such as incremental dynamic exercise has not been established. The aim of this study was to determine the reliability of NIRS-derived mBF and mV̇O2 responses from incremental dynamic exercise. Measurements of mBF and mV̇O2 were collected in the vastus lateralis of 12 healthy, physically active adults [seven men and five women; 25 (SD 6) years old] during three non-consecutive visits within 10 days. After 10 min rest, participants performed 3 min of rhythmic isotonic knee extension (one extension every 4 s) at 5, 10, 15, 20, 25 and 30% of maximal voluntary contraction (MVC), before four venous occlusions and then two arterial occlusions. The mBF and mV̇O2 increased proportionally with intensity [from 0.55 to 7.68 ml min-1  (100 ml)-1 and from 0.05 to 1.86 ml O2  min-1  (100 g)-1 , respectively] up to 25% MVC, where they began to plateau at 30% MVC. Moreover, an mBF/mV̇O2 muscle oxygen consumption ratio of ∼5 was consistent for all exercise stages. The intraclass correlation coefficient for mBF indicated high to very high reliability for 10-30% MVC (0.82-0.9). There was very high reliability for mV̇O2 across all exercise stages (intraclass correlation coefficient 0.91-0.96). In conclusion, NIRS can reliably assess muscle blood flow and oxygen consumption responses to low- to moderate-intensity exercise, meriting potential applications in clinical diagnosis and therapeutic assessment.

Poor sleep quality, antepartum depression and suicidal ideation among pregnant women.

OBJECTIVE: To evaluate the independent and combined associations of maternal self-reported poor sleep quality and antepartum depression with suicidal ideation during the third trimester METHODS: A cross-sectional study was conducted among 1298 pregnant women (between 24 and 28 gestational weeks) attending prenatal clinics in Lima, Peru. Antepartum depression and suicidal ideation were assessed using the Patient Health Questionnaire-9 (PHQ-9). The Pittsburgh Sleep Quality Index (PSQI) questionnaire was used to assess sleep quality. Multivariate logistical regression procedures were used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) after adjusting for putative confounders. RESULTS: Approximately, 17% of women were classified as having poor sleep quality (defined using the recommended criteria of PSQI global score of >5 vs. ≤5). Further, the prevalence of antepartum depression and suicidal ideation were 10.3% and 8.5%, respectively in this cohort. After adjusting for confounders including depression, poor sleep quality was associated with a 2.81-fold increased odds of suicidal ideation (OR=2.81; 95% CI 1.78-4.45). When assessed as a continuous variable, each 1-unit increase in the global PSQI score resulted in a 28% increase in odds for suicidal ideation, even after adjusting for depression (OR=1.28; 95% CI 1.15-1.41). The odds of suicidal ideation was particularly high among depressed women with poor sleep quality (OR=13.56 95% CI 7.53-24.41) as compared with women without either risk factor. LIMITATIONS: This cross-sectional study utilized self-reported data. Causality cannot be inferred, and results may not be fully generalizable. CONCLUSION: Poor sleep quality, even after adjusting for depression, is associated with antepartum suicidal ideation. Our findings support the need to explore sleep-focused interventions for pregnant women.