Objective: Assessment of untoward symptomatic outcomes and major/minor complications occurring in... more Objective: Assessment of untoward symptomatic outcomes and major/minor complications occurring in children with percutaneous gastrojejunal tubes (GJT) in place. Methods: A retrospective chart review of 28 patients with GJTs was performed. The diagnoses for these patients were: neurological diseases, 23; respiratory diseases, two; and gastrointestinal tract disorders, three. Twenty-three tubes were placed radiologically, four endoscopically, and one surgically. Patients' age range was between 1.5 and 180 months (mean 47.2 months), and weight at the time of tube insertion was between 2.28 and 42.7 kg. (mean 11.7 kg.). Duration of follow-up was from 1 to 49 months (mean 17.3 months). The patients were evaluated for the persistence or new development of the following symptoms: vomiting, hematemesis, abdominal pain, constipation, diarrhea, pain at the site of gastrostomy tube insertion, stridor with feeds, and dumping. Minor complications (including breakage, partial/total displacement, or dislodgement of GJT, tube occlusion, tube leakage, transient infection and/or granuloma at the gastrostomy site, and continued gastroesophageal reflux post-GJT conversion), as well as major complications (requiring surgical intervention) and mortality, were assessed. Results: One or more symptoms either persisted or developed de novo in 20 children after tube insertion. Vomiting was the most common symptom, being present in 16 patients. One or more minor complication occurred in 21 patients; the most common was the accidental dislodgement of the jejunal feeding catheter. Major complications occurred in 11 patients (e.g., fundoplication in seven patients). Five patients died. Six patients had no complications; at the time of GJT placement, their mean age (93.3 months) was significantly older (p = 0.0269) and mean weight (21.3 kg.) significantly heavier (p = 0.0067) than those of children reporting major complications. Conclusions: We conclude that ongoing or new gastrointestinal symptoms and minor complications are common in children with GJT. However, GJT placement in larger children is associated with fewer complications than in smaller children.
Journal of Pediatric Gastroenterology and Nutrition, Sep 1, 2016
The aim of the study was to determine whether embedding into the radiology report a patient-speci... more The aim of the study was to determine whether embedding into the radiology report a patient-specific plan in the event of gastrojejunostomy (GJ) tube dysfunction reduces the need for after-hours utilization of pediatric interventional radiology resources for the replacement of GJ tubes. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved retrospective repeated cross-sectional study of patients requiring after-hours (5 PM-7 AM) or weekend (Saturday and Sunday) GJ tube replacement at a dedicated children's hospital, before and after the inclusion of a patient-specific plan in the radiology report as part of the electronic medical record. During a 6-month period before the inclusion of a patient-specific plan, there were 242 total GJ tube changes performed by the pediatric interventional radiology service under image guidance. Twenty-six (10.7%) of these procedures were performed outside of standard operating hours at the request of the emergency department (ED) (6/26), inpatient service (8/26), or patient/caregiver (12/26). Of the 8 inpatients, 3 were admitted from the ED for the sole purpose of tube replacement. Data were again collected for 6 months following inclusion of a patient-specific plan during the same seasonal period of the following year. During this period, 240 total image-guided changes were performed. Fifteen (6.2%) were performed outside of standard operating hours at the request of the ED (2/15), inpatient service (4/15), or patient/caregiver (9/15). No patients were admitted for GJ tube replacement procedures following implementation of the enhanced reporting policy. These data indicate a trend toward reduced after-hours resource utilization for GJ tube replacement requests by the ED (23.1%-13.3%), inpatient service (30.8%-26.7%), and all patients (14.7%-11%). Fewer after-hours GJ tube changes reduced cost by proportionately reducing hourly compensation for interventional radiology nurses and technicians. Our single-center data suggest that the inclusion of patient-specific recommendations at the end of each radiology GJ tube procedure note, generated in collaboration with the feeding service or primary medical provider, reduces off-hour resource utilization in patients who could otherwise have their tubes replaced during standard operating hours with image guidance. Avoidance of tube-related admissions is likely the greatest source of cost savings, followed by lower radiology technical support costs. Cost savings related to improved ED workflow and reduced patient/family anxiety are difficult to quantify, but likely significant. Future studies should be designed to quantify these savings and to assess the effect of this intervention on patient/caregiver satisfaction.
To the Editor.— Dr Hocker and his colleagues1 are to be commended for taking on the difficult tas... more To the Editor.— Dr Hocker and his colleagues1 are to be commended for taking on the difficult task of evaluating the success of ECMO in early-onset group B streptococcal infection when a controlled trial is ethically and practically not feasible. In their study they used historical controls (a commonly criticized method, but all that is realistically available) to identify risk factors for early-onset group B streptococcal sepsis and to evaluate the effectiveness of ECMO intervention.
When studying the effect of different drugs or different dose levels (or more generally, simply d... more When studying the effect of different drugs or different dose levels (or more generally, simply different treatments) on people, the variability between responses of different people can overwhelm any treatment differences. That is why crossover designs, where each person gets one of each drug or each dose level, are so appealing. Since the order in which people receive a drug may have an effect, the crossover is designed to balance out any period effects. When a carryover effect occurs, that is, when the drug’s effect carries over to the next period, there may be difficulties. Nonetheless, the crossover is very appealing theoretically, with power to detect very small differences with relatively much smaller sample sizes. That is the good news.
Learning Objectives: The purpose of our study is to compare the rate of both blood stream infecti... more Learning Objectives: The purpose of our study is to compare the rate of both blood stream infection (BSI) and venous thromboembolism (VTE) in central venous catheters (CVC) versus peripherally inserted central catheters (PICC). There is a growing body of literature for adult patients describing overall increased complication rates associated with PICC lines when compared to CVCs. It is not known if the rates of BSI and VTE differ with the type of central venous catheter placed in children. Based on the current available adult data, we hypothesize that the infection rates for PICC lines and CVCs will be similar and that the overall complication rate for PICC lines will be higher in pediatric patients. Methods: This is retrospective cohort study using chart review of patients admitted to a quaternary-care pediatric hospital from January 2012 to December 2015. All patients with central venous catheters (CVC and PICC) placed during hospital admission over the study dates were included. ...
In regression, the decision about which variables to include and in which form they should be inc... more In regression, the decision about which variables to include and in which form they should be included in the model can be very difficult. Screening variables can be very tedious; perhaps that is the reason why many models seen, for example, in nutrition, only include main effects. However, because of its uses in screening, a tree can JMPstart your regression model analysis. All types of variables can be included in a tree, including variables with missing values and variables that are highly interrelated. This enables consideration of the form of the variables to be included. Because of the tree methodology, cutpoints for variables that best optimize a function are given, so it is possible to consider new variables generated from the old variables. Trees are also useful for exploring the interaction of variables. For example, if a variable appears on one side of a tree and not on the other, it suggests that there is indeed an effect of interaction. Using a large nutrition dataset, ...
To assess the effects of marginal biotin deficiency on immune function and thereby evaluate immun... more To assess the effects of marginal biotin deficiency on immune function and thereby evaluate immune function as a potential marker for impaired biotin status, we investigated immune function in a rat model during progression from sufficiency to moderate biotin deficiency. As immune function indicators, we assessed the IgG response to a vaccine and the cytokine responses and relative proportions of lymphocyte subpopulations in the immunocytes in blood, spleen and thymus. Neither phenotype nor organ redistribution of lymphocytes differed between biotin-deficient and biotin-sufficient rats. Assessment of immune function by mitogen T cell proliferation, mitogen-induced interferon-␥ and interleukin-4 levels, IgG antibody responses and natural killer cell activity were not significantly different in mild to moderately biotin-deficient rats compared with biotin-sufficient controls. The absence of effects on immune function was not attributable to failure to induce biotin deficiency; the rats exhibited unequivocal evidence of biotin deficiency, including reduced hepatic biotin and impaired leucine metabolism resulting from deficiency of the biotin-dependent enzyme methylcrotonyl-CoA carboxylase. We conclude that the immune markers examined are not promising candidates as indicators of mild to moderate deficiency in humans.
During exercise, as heart rate (HR) increases, the QT interval of the electrocardiogram shortens.... more During exercise, as heart rate (HR) increases, the QT interval of the electrocardiogram shortens. The mechanism(s) involved in this QT shortening has not been clearly defined. To distinguish the influence of increased circulating catecholamines from myocardial efferent stimulation, the relationship between HR and QT interval was investigated during exercise and cardiovascular reflex stimulation in cardiac transplant patients and normal control subjects. Because of cardiac denervation, increases in HR in these patients are solely due to circulating catecholamines and thus allow isolation of their effect on the QT interval. Twenty-one cardiac transplant patients were studied and compared with 16 normal control subjects. The QT-HR relationship was determined according to an exponential model during treadmill exercise in both groups [QT = 0.12 + 0.492e(-0.008.HR) and QT = 0.12 + 0.459e(-0.007.HR) in normal subjects and transplant patients, respectively] and was statistically similar bet...
Single ventricle heart disease with aortic arch hypoplasia has high morbidity and mortality, with... more Single ventricle heart disease with aortic arch hypoplasia has high morbidity and mortality, with the greatest risk after stage 1 palliation. Residual lesions often require catheter-based or surgical reintervention to minimize risk. We sought to describe the types, frequency, and risk factors for re-intervention between stage 1 and stage 2 palliation, utilizing the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry. The NPC-QIC registry, consisting of patients discharged after stage 1 palliation, was queried. Hybrid stage 1 palliation patients were excluded from this study. The primary risk factor was shunt type and the primary outcome was re-intervention. Of 1156 patients, (50%) had re-intervention. There was no difference in total rate of re-intervention by shunt type (BT shunt 52% vs. RVPA shunt 48%; P = .17). Patients with a BT shunt had increased re-intervention during stage 1 hospitalization (P =.002). During the interstage period, following dis...
Background: Severe traumatic brain injury (sTBI) is the leading cause of morbidity and mortality ... more Background: Severe traumatic brain injury (sTBI) is the leading cause of morbidity and mortality from trauma. Brain Trauma Foundation guidelines recommend intracranial pressure (ICP) monitoring in sTBI. We hypothesized that early ICP monitor placement was associated with better outcomes in children. Methods: This was a retrospective study of children with sTBI admitted to the participating pediatric intensive care units (PICUs) and entered into the Virtual Pediatric Systems (VPS), LLC, database between 1 January 2010 and 31 December 2015. We compared outcomes of patients who had an ICP monitor placed early (≤6 h from PICU admission) to those with later placement (> 6 to < 72 h). We collected demographics, diagnoses, procedure data, illness severity scores, outcomes, and site data. Multivariable regression analysis was used to identify variables independently associated with outcomes. Results: Twenty-seven percent of 3,608 patients with sTBI underwent ICP monitoring, 355 in the...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2018
To assess the current training in brain death examination provided during pediatric critical care... more To assess the current training in brain death examination provided during pediatric critical care medicine fellowship. Internet-based survey. United States pediatric critical care medicine fellowship programs. Sixty-four pediatric critical care medicine fellowship program directors and 230 current pediatric critical care medicine fellows/recent graduates were invited to participate. Participants were asked demographic questions related to their fellowship programs, training currently provided at their fellowship programs, previous experience with brain death examinations (fellows/graduates), and perceptions regarding the adequacy of current training. Twenty-nine program directors (45%) and 91 current fellows/graduates (40%) responded. Third-year fellows reported having performed a median of five examinations (interquartile range, 3-6). On a five-point Likert scale, 93% of program directors responded they "agree" or "strongly agree" that their fellows receive enou...
Journal of pediatric hematology/oncology, Jan 31, 2018
In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous... more In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous catheter (CVC) have been identified as significant risk factors for the development of a venous thromboembolism (VTE). There remain little data regarding CVC factors associated with CVC-related VTE. Using the VTE and oncology database in a quaternary care center, a retrospective cohort study was conducted in children below 18 years old with hematologic cancer from November 5, 2012 to April 4, 2016. Patient, CVC factors, and VTE occurrence were analyzed to identify significant patient and CVC factors associated with the development of clinically identified CVC-related VTE. Utilizing the χ, Mann-Whitney, and the Fisher exact tests, patient factors were compared across VTE yes/no groups. Of the 198 study patients, 22 VTE cases were identified. Eighteen VTE events were CVC-associated, occurring in 9% of study population. Peripherally inserted central catheter lines and older ages were assoc...
Telemedicine journal and e-health : the official journal of the American Telemedicine Association, Jan 3, 2018
Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to b... more Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to better prepare individuals to manage anaphylaxis in the community. Didactic training as the sole method of anaphylaxis education has been shown to be ineffective. We developed a smartphone-based interactive teaching tool with decision support and epinephrine auto-injector (EAI) training to provide education accessible beyond the clinic. This study consisted of two parts: (1) Use of food allergy scenarios to assess the decision support's ability to improve allergic reaction management knowledge. (2) An assessment of our EAI training module on participant's ability to correctly demonstrate the use of an EAI by comparing it to label instructions. Twenty-two adolescents were recruited. The median (range) baseline number of correct answers on the scenarios before the intervention was 9 (3-11). All subjects improved with decision support, increasing to 11 (9-12) (p < .001). The media...
World journal for pediatric & congenital heart surgery, Jul 1, 2018
Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute t... more Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute to bleeding and morbidity. Rotational thromboelastometry (ROTEM) is a viscoelastic assay with a rapid turnaround time. Data validating ROTEM during neonatal cardiac surgery remain limited. This study examined perioperative hemostatic trends in neonates treated with standardized platelet and cryoprecipitate transfusion during CPB. We hypothesized that ROTEM would predict thrombocytopenia, hypofibrinogenemia, and the correction thereof. Forty-four neonates undergoing CPB were included in this prospective observational study. Blood samples were obtained at Baseline, On CPB, Post-CPB, and Postoperative. The ROTEM analysis included extrinsically activated (Extem) and fibrinogen-specific (Fibtem) assays. Platelet-specific thromboelastometry (Pltem) values were calculated. Platelet and cryoprecipitate transfusion was initiated prior to termination of CPB. Platelet count and Extem amplitude decre...
Objective: Assessment of untoward symptomatic outcomes and major/minor complications occurring in... more Objective: Assessment of untoward symptomatic outcomes and major/minor complications occurring in children with percutaneous gastrojejunal tubes (GJT) in place. Methods: A retrospective chart review of 28 patients with GJTs was performed. The diagnoses for these patients were: neurological diseases, 23; respiratory diseases, two; and gastrointestinal tract disorders, three. Twenty-three tubes were placed radiologically, four endoscopically, and one surgically. Patients' age range was between 1.5 and 180 months (mean 47.2 months), and weight at the time of tube insertion was between 2.28 and 42.7 kg. (mean 11.7 kg.). Duration of follow-up was from 1 to 49 months (mean 17.3 months). The patients were evaluated for the persistence or new development of the following symptoms: vomiting, hematemesis, abdominal pain, constipation, diarrhea, pain at the site of gastrostomy tube insertion, stridor with feeds, and dumping. Minor complications (including breakage, partial/total displacement, or dislodgement of GJT, tube occlusion, tube leakage, transient infection and/or granuloma at the gastrostomy site, and continued gastroesophageal reflux post-GJT conversion), as well as major complications (requiring surgical intervention) and mortality, were assessed. Results: One or more symptoms either persisted or developed de novo in 20 children after tube insertion. Vomiting was the most common symptom, being present in 16 patients. One or more minor complication occurred in 21 patients; the most common was the accidental dislodgement of the jejunal feeding catheter. Major complications occurred in 11 patients (e.g., fundoplication in seven patients). Five patients died. Six patients had no complications; at the time of GJT placement, their mean age (93.3 months) was significantly older (p = 0.0269) and mean weight (21.3 kg.) significantly heavier (p = 0.0067) than those of children reporting major complications. Conclusions: We conclude that ongoing or new gastrointestinal symptoms and minor complications are common in children with GJT. However, GJT placement in larger children is associated with fewer complications than in smaller children.
Journal of Pediatric Gastroenterology and Nutrition, Sep 1, 2016
The aim of the study was to determine whether embedding into the radiology report a patient-speci... more The aim of the study was to determine whether embedding into the radiology report a patient-specific plan in the event of gastrojejunostomy (GJ) tube dysfunction reduces the need for after-hours utilization of pediatric interventional radiology resources for the replacement of GJ tubes. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved retrospective repeated cross-sectional study of patients requiring after-hours (5 PM-7 AM) or weekend (Saturday and Sunday) GJ tube replacement at a dedicated children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital, before and after the inclusion of a patient-specific plan in the radiology report as part of the electronic medical record. During a 6-month period before the inclusion of a patient-specific plan, there were 242 total GJ tube changes performed by the pediatric interventional radiology service under image guidance. Twenty-six (10.7%) of these procedures were performed outside of standard operating hours at the request of the emergency department (ED) (6/26), inpatient service (8/26), or patient/caregiver (12/26). Of the 8 inpatients, 3 were admitted from the ED for the sole purpose of tube replacement. Data were again collected for 6 months following inclusion of a patient-specific plan during the same seasonal period of the following year. During this period, 240 total image-guided changes were performed. Fifteen (6.2%) were performed outside of standard operating hours at the request of the ED (2/15), inpatient service (4/15), or patient/caregiver (9/15). No patients were admitted for GJ tube replacement procedures following implementation of the enhanced reporting policy. These data indicate a trend toward reduced after-hours resource utilization for GJ tube replacement requests by the ED (23.1%-13.3%), inpatient service (30.8%-26.7%), and all patients (14.7%-11%). Fewer after-hours GJ tube changes reduced cost by proportionately reducing hourly compensation for interventional radiology nurses and technicians. Our single-center data suggest that the inclusion of patient-specific recommendations at the end of each radiology GJ tube procedure note, generated in collaboration with the feeding service or primary medical provider, reduces off-hour resource utilization in patients who could otherwise have their tubes replaced during standard operating hours with image guidance. Avoidance of tube-related admissions is likely the greatest source of cost savings, followed by lower radiology technical support costs. Cost savings related to improved ED workflow and reduced patient/family anxiety are difficult to quantify, but likely significant. Future studies should be designed to quantify these savings and to assess the effect of this intervention on patient/caregiver satisfaction.
To the Editor.— Dr Hocker and his colleagues1 are to be commended for taking on the difficult tas... more To the Editor.— Dr Hocker and his colleagues1 are to be commended for taking on the difficult task of evaluating the success of ECMO in early-onset group B streptococcal infection when a controlled trial is ethically and practically not feasible. In their study they used historical controls (a commonly criticized method, but all that is realistically available) to identify risk factors for early-onset group B streptococcal sepsis and to evaluate the effectiveness of ECMO intervention.
When studying the effect of different drugs or different dose levels (or more generally, simply d... more When studying the effect of different drugs or different dose levels (or more generally, simply different treatments) on people, the variability between responses of different people can overwhelm any treatment differences. That is why crossover designs, where each person gets one of each drug or each dose level, are so appealing. Since the order in which people receive a drug may have an effect, the crossover is designed to balance out any period effects. When a carryover effect occurs, that is, when the drug’s effect carries over to the next period, there may be difficulties. Nonetheless, the crossover is very appealing theoretically, with power to detect very small differences with relatively much smaller sample sizes. That is the good news.
Learning Objectives: The purpose of our study is to compare the rate of both blood stream infecti... more Learning Objectives: The purpose of our study is to compare the rate of both blood stream infection (BSI) and venous thromboembolism (VTE) in central venous catheters (CVC) versus peripherally inserted central catheters (PICC). There is a growing body of literature for adult patients describing overall increased complication rates associated with PICC lines when compared to CVCs. It is not known if the rates of BSI and VTE differ with the type of central venous catheter placed in children. Based on the current available adult data, we hypothesize that the infection rates for PICC lines and CVCs will be similar and that the overall complication rate for PICC lines will be higher in pediatric patients. Methods: This is retrospective cohort study using chart review of patients admitted to a quaternary-care pediatric hospital from January 2012 to December 2015. All patients with central venous catheters (CVC and PICC) placed during hospital admission over the study dates were included. ...
In regression, the decision about which variables to include and in which form they should be inc... more In regression, the decision about which variables to include and in which form they should be included in the model can be very difficult. Screening variables can be very tedious; perhaps that is the reason why many models seen, for example, in nutrition, only include main effects. However, because of its uses in screening, a tree can JMPstart your regression model analysis. All types of variables can be included in a tree, including variables with missing values and variables that are highly interrelated. This enables consideration of the form of the variables to be included. Because of the tree methodology, cutpoints for variables that best optimize a function are given, so it is possible to consider new variables generated from the old variables. Trees are also useful for exploring the interaction of variables. For example, if a variable appears on one side of a tree and not on the other, it suggests that there is indeed an effect of interaction. Using a large nutrition dataset, ...
To assess the effects of marginal biotin deficiency on immune function and thereby evaluate immun... more To assess the effects of marginal biotin deficiency on immune function and thereby evaluate immune function as a potential marker for impaired biotin status, we investigated immune function in a rat model during progression from sufficiency to moderate biotin deficiency. As immune function indicators, we assessed the IgG response to a vaccine and the cytokine responses and relative proportions of lymphocyte subpopulations in the immunocytes in blood, spleen and thymus. Neither phenotype nor organ redistribution of lymphocytes differed between biotin-deficient and biotin-sufficient rats. Assessment of immune function by mitogen T cell proliferation, mitogen-induced interferon-␥ and interleukin-4 levels, IgG antibody responses and natural killer cell activity were not significantly different in mild to moderately biotin-deficient rats compared with biotin-sufficient controls. The absence of effects on immune function was not attributable to failure to induce biotin deficiency; the rats exhibited unequivocal evidence of biotin deficiency, including reduced hepatic biotin and impaired leucine metabolism resulting from deficiency of the biotin-dependent enzyme methylcrotonyl-CoA carboxylase. We conclude that the immune markers examined are not promising candidates as indicators of mild to moderate deficiency in humans.
During exercise, as heart rate (HR) increases, the QT interval of the electrocardiogram shortens.... more During exercise, as heart rate (HR) increases, the QT interval of the electrocardiogram shortens. The mechanism(s) involved in this QT shortening has not been clearly defined. To distinguish the influence of increased circulating catecholamines from myocardial efferent stimulation, the relationship between HR and QT interval was investigated during exercise and cardiovascular reflex stimulation in cardiac transplant patients and normal control subjects. Because of cardiac denervation, increases in HR in these patients are solely due to circulating catecholamines and thus allow isolation of their effect on the QT interval. Twenty-one cardiac transplant patients were studied and compared with 16 normal control subjects. The QT-HR relationship was determined according to an exponential model during treadmill exercise in both groups [QT = 0.12 + 0.492e(-0.008.HR) and QT = 0.12 + 0.459e(-0.007.HR) in normal subjects and transplant patients, respectively] and was statistically similar bet...
Single ventricle heart disease with aortic arch hypoplasia has high morbidity and mortality, with... more Single ventricle heart disease with aortic arch hypoplasia has high morbidity and mortality, with the greatest risk after stage 1 palliation. Residual lesions often require catheter-based or surgical reintervention to minimize risk. We sought to describe the types, frequency, and risk factors for re-intervention between stage 1 and stage 2 palliation, utilizing the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry. The NPC-QIC registry, consisting of patients discharged after stage 1 palliation, was queried. Hybrid stage 1 palliation patients were excluded from this study. The primary risk factor was shunt type and the primary outcome was re-intervention. Of 1156 patients, (50%) had re-intervention. There was no difference in total rate of re-intervention by shunt type (BT shunt 52% vs. RVPA shunt 48%; P = .17). Patients with a BT shunt had increased re-intervention during stage 1 hospitalization (P =.002). During the interstage period, following dis...
Background: Severe traumatic brain injury (sTBI) is the leading cause of morbidity and mortality ... more Background: Severe traumatic brain injury (sTBI) is the leading cause of morbidity and mortality from trauma. Brain Trauma Foundation guidelines recommend intracranial pressure (ICP) monitoring in sTBI. We hypothesized that early ICP monitor placement was associated with better outcomes in children. Methods: This was a retrospective study of children with sTBI admitted to the participating pediatric intensive care units (PICUs) and entered into the Virtual Pediatric Systems (VPS), LLC, database between 1 January 2010 and 31 December 2015. We compared outcomes of patients who had an ICP monitor placed early (≤6 h from PICU admission) to those with later placement (> 6 to < 72 h). We collected demographics, diagnoses, procedure data, illness severity scores, outcomes, and site data. Multivariable regression analysis was used to identify variables independently associated with outcomes. Results: Twenty-seven percent of 3,608 patients with sTBI underwent ICP monitoring, 355 in the...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2018
To assess the current training in brain death examination provided during pediatric critical care... more To assess the current training in brain death examination provided during pediatric critical care medicine fellowship. Internet-based survey. United States pediatric critical care medicine fellowship programs. Sixty-four pediatric critical care medicine fellowship program directors and 230 current pediatric critical care medicine fellows/recent graduates were invited to participate. Participants were asked demographic questions related to their fellowship programs, training currently provided at their fellowship programs, previous experience with brain death examinations (fellows/graduates), and perceptions regarding the adequacy of current training. Twenty-nine program directors (45%) and 91 current fellows/graduates (40%) responded. Third-year fellows reported having performed a median of five examinations (interquartile range, 3-6). On a five-point Likert scale, 93% of program directors responded they "agree" or "strongly agree" that their fellows receive enou...
Journal of pediatric hematology/oncology, Jan 31, 2018
In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous... more In pediatric oncology, the diagnosis of a hematologic malignancy and presence of a central venous catheter (CVC) have been identified as significant risk factors for the development of a venous thromboembolism (VTE). There remain little data regarding CVC factors associated with CVC-related VTE. Using the VTE and oncology database in a quaternary care center, a retrospective cohort study was conducted in children below 18 years old with hematologic cancer from November 5, 2012 to April 4, 2016. Patient, CVC factors, and VTE occurrence were analyzed to identify significant patient and CVC factors associated with the development of clinically identified CVC-related VTE. Utilizing the χ, Mann-Whitney, and the Fisher exact tests, patient factors were compared across VTE yes/no groups. Of the 198 study patients, 22 VTE cases were identified. Eighteen VTE events were CVC-associated, occurring in 9% of study population. Peripherally inserted central catheter lines and older ages were assoc...
Telemedicine journal and e-health : the official journal of the American Telemedicine Association, Jan 3, 2018
Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to b... more Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to better prepare individuals to manage anaphylaxis in the community. Didactic training as the sole method of anaphylaxis education has been shown to be ineffective. We developed a smartphone-based interactive teaching tool with decision support and epinephrine auto-injector (EAI) training to provide education accessible beyond the clinic. This study consisted of two parts: (1) Use of food allergy scenarios to assess the decision support's ability to improve allergic reaction management knowledge. (2) An assessment of our EAI training module on participant's ability to correctly demonstrate the use of an EAI by comparing it to label instructions. Twenty-two adolescents were recruited. The median (range) baseline number of correct answers on the scenarios before the intervention was 9 (3-11). All subjects improved with decision support, increasing to 11 (9-12) (p < .001). The media...
World journal for pediatric & congenital heart surgery, Jul 1, 2018
Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute t... more Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute to bleeding and morbidity. Rotational thromboelastometry (ROTEM) is a viscoelastic assay with a rapid turnaround time. Data validating ROTEM during neonatal cardiac surgery remain limited. This study examined perioperative hemostatic trends in neonates treated with standardized platelet and cryoprecipitate transfusion during CPB. We hypothesized that ROTEM would predict thrombocytopenia, hypofibrinogenemia, and the correction thereof. Forty-four neonates undergoing CPB were included in this prospective observational study. Blood samples were obtained at Baseline, On CPB, Post-CPB, and Postoperative. The ROTEM analysis included extrinsically activated (Extem) and fibrinogen-specific (Fibtem) assays. Platelet-specific thromboelastometry (Pltem) values were calculated. Platelet and cryoprecipitate transfusion was initiated prior to termination of CPB. Platelet count and Extem amplitude decre...
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Papers by pippa simpson