Jacobs Institute of Women's Health
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Association of Physiologic Parameters with Neurologic Outcome After Arteriovenous Malformation Rupture in Children
No full textEvidence to guide the critical care management of children with ruptured brain arteriovenous malformations is lacking. We aimed to determine whether there are associations between physiologic parameters and outcome in children with ruptured brain arteriovenous malformations. We performed a single-center retrospective review of patients ≤18 years of age with a ruptured brain arteriovenous malformation from 2011 to 2023. Categorization of outcome was based on the Pediatric Stroke Outcome Measure. Descriptive statistics were used. Most patients with an arteriovenous malformation rupture had a poor outcome at discharge (31/49, 63%) and in follow-up at 3-12 months (21/37, 57%). Patients who were normothermic and normoglycemic for the first 7 days after arteriovenous malformation rupture were less likely to have a poor outcome at discharge than those who had a temperature ≥38 °C (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.04-0.52; P = .01) or a blood glucose ≥200 mg/dL (OR 0.11, 95% CI 0.01-0.92; P = .04). A lower minimum hemoglobin concentration (10.00 g/dL [standard deviation (SD) 1.67] vs 12.46 g/dL [SD 6.29], t(47) 2.07, P = .04) and a higher average partial pressure of carbon dioxide (Paco) (40.98 mm Hg [SD 4.30] vs 35.58 mm Hg [SD 7.72], t(47) -2.09, P = .046) were also associated with a poor discharge outcome. A higher average maximum temperature was associated with a poor outcome in follow-up (37.46° C [SD 0.49] vs 37.09 °C [SD 0.59], t(47) -2.09; P = .04). Temperature, blood glucose, hemoglobin concentration, and Paco are potentially modifiable parameters that could be targeted by quality improvement interventions to improve outcomes in this population
Themes in the Management of Pediatric Brain Death Contestation: Exploratory Qualitative Work From Multidisciplinary Health Professionals in the United States
No full textOBJECTIVES: To explore health professionals\u27 experiences of contested pediatric brain death/death by neurologic criteria (BD/DNC) cases, including factors contributing to conflict, resource needs and utilization, perceived utility of supports available, and case resolution and aftermath. DESIGN AND METHODS: Inductive thematic analysis of semistructured interviews with members of the Society of Critical Care Medicine (SCCM) Contestation of Pediatric Brain Death Task Force. SETTING: Ten institutions across seven U.S. states and the District of Columbia. PARTICIPANTS: Nineteen Task Force members were interviewed in 2023, including pediatric intensivists, neurologists, nurses, respiratory therapists, attorneys, palliative care clinicians, social workers, ethicists, and hospital leadership. Task Force members were recruited primarily because of their experience with contested BD/DNC, although some were recruited because of expertise in other relevant topics, such as communication, information acquisition in BD/DNC, and health equity. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified five themes relevant to managing pediatric BD/DNC contestation: 1) personnel to consider involving, including subspecialty consultation, social work, hospital leadership and administration, ethics teams, legal counsel, and security; 2) timelines to maintain, including factors to consider when deciding the most appropriate family accommodations; 3) support for families and patients, including strategies to enhance communication, identifying and mitigating mistrust, and connecting families with support both within and outside the hospital; 4) support for staff, including disseminating information throughout the care team, staff support for one another, and establishing written documentation and policies; and 5) complementary strategies that may augment approaches to BD/DNC contestation, such as policies addressing requests for potentially inappropriate treatment. CONCLUSIONS: Family contestation of pediatric BD/DNC challenges all parties involved. The five themes identified from our qualitative analysis of interviews with experienced professionals do not constitute SCCM clinical practice guidance, but they will be used to inform the development of approaches to BD/DNC contestation through further scholarship and community consultation
Correction: Differential associations of somatic and cognitive-affective symptoms of depression with inflammation and insulin resistance: cross-sectional and longitudinal results from the Emotional Distress Sub-Study of the GRADE study
No full textEffect of host-protein test (TRAIL/IP-10/CRP) on antibiotic prescription and emergency department or urgent care center return visits: The JUNO pilot randomized controlled trial
No full textOBJECTIVES: Determining etiology for adults with symptoms of lower respiratory tract infection (LRTI) is challenging. MeMed BV (MMBV), an FDA-cleared blood test, computationally integrates the levels of three host proteins to differentiate bacterial and viral infections. We evaluated MMBV\u27s impact on safe antibiotic prescribing at emergency department/urgent care centers (ED/UC). METHODS: The JUNO randomized controlled trial (RCT; NCT05762302) was a prespecified pilot phase of the JUPITER RCT. JUNO enrolled adult ED/UC patients with LRTI symptoms and clinician\u27s consideration for antibiotic treatment. Inclusion criteria were fever within 7 days and one of cough, sputum production, dyspnea, or auscultation abnormality. Exclusion criteria were prior antibiotic use or immunosuppression. Patients were randomized to standard care (SC) or SC plus MMBV arms. JUNO\u27s primary objective was to assess antibiotic prescription rate in the SC arm; the secondary objective was to assess JUPITER\u27s study design. RESULTS: Eleven centers randomized 260 patients, with 214 included (106 SC, 108 MMBV). Median (IQR) age was 40 (28-55.8) years, 57% were female, and 78.5% were enrolled at ED. Common symptoms were cough (93.0%) and chills (70.0%). Overall, antibiotic prescription rates were 30% (95% CI 22% to 40%) and 24% (95% CI 17% to 33%) in the SC arm versus the MMBV (absolute difference of -6% [95% CI -18% to 6%]). More antibiotics were given with bacterial MMBV scores (41% vs. 78%, absolute difference 37%, 95% CI 6% to 61%; n = 40) and less with viral MMBV scores (25% vs. 12%, absolute difference -13%, 95% CI -25% to 0%; n = 144) in the SC versus MMBV arms. There was no increase in ED/UC return visits (8% vs. 3%, difference -6%, 95% CI -12% to 1%) or hospitalizations (3% vs. 0%, difference -3%, 95% CI -7% to 1%) in the SC arm versus the MMBV arm. CONCLUSIONS: JUNO demonstrated that JUPITER\u27s design results in 30% antibiotic prescription rate in the SC arm. JUNO supports that MMBV optimizes antibiotic prescriptions without increasing return ED/UC visits or hospitalizations
Screening for Food Insecurity: US Preventive Services Task Force Recommendation Statement
No full textIMPORTANCE: According to survey data, 12.8% of households experienced food insecurity in 2022, with 7.7% of households experiencing low food security and 5.1% experiencing very low food security. Nearly one-third of households with incomes below the federal poverty threshold are food insecure. Food insecurity is one among a multitude of medical, psychological, and social conditions common among economically disadvantaged households. OBJECTIVE: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on the benefits and harms of screening for food insecurity in the health care setting. POPULATION: Children, adolescents, and adults. EVIDENCE ASSESSMENT: The USPSTF concludes that the evidence is insufficient and the balance of benefits and harms for screening for food insecurity on health outcomes in the primary care setting cannot be determined. RECOMMENDATION: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for food insecurity on health outcomes in the primary care setting. (I statement)
Diagnosis and Management of Pediatric Ballistic Fractures
No full textOfficially declared a public health crisis, firearm violence is a growing epidemic in the United States. Pediatric firearm-related injuries are now the number one cause of death of children and adolescents in the United States, with approximately 22% of all injuries resulting in fracture. Knowledge regarding gunshot wound injury and management is increasingly relevant to orthopaedic surgeons as the rate of pediatric gun violence continues to climb across the nation. Previous guidelines and recommendations were written when high-velocity weapons and deforming bullets were only available for military usage. Widespread accessibility and use of firearms among civilians has contributed to increasing rates of ballistic injuries among children and adolescents. This review aims to aggregate the literature regarding ballistic fracture etiology, treatment, and management for the pediatric population
Injury caseload, pattern and time of presentation to emergency services in Mozambique: A pragmatic, multicentre, observational study
No full textBACKGROUND: Rapid population growth and urbanisation raise a critical need to better understand the burden of injuries in sub-Saharan Africa. We assessed the pattern of service demand for injuries at emergency department (ED) in urban areas of Mozambique. METHODS: This prospective, multi-centric, observational study was conducted in EDs in southern (Maputo), central (Beira) and northern (Nampula) of Mozambique. We randomly selected 7809 cases (age ≥1 years) during the seasonally distinct months of April/2016-2017 and October/2017. Data on patients\u27 demographics, nature of injury and clinical outcomes were collected. RESULTS: Overall, 1881/7809 (26.2 %) emergency cases comprising 518 children (58.5 % male, aged 4.6 ± 2.5 years), 324 adolescents (64.8 % male, 14.7 ± 3.0 years) and 10,39 adults (60.8 % male, 34.5 ± 13.0 years) presented with injury. The arms, legs and head were most affected in both children (518 with 795 injuries) and adults (1039 with 1496 injuries). The diversity of injuries increased with older age. Injury cases predominantly presented during daylight hours (from 0900 to 1900) with age-differentials evident. There were proportionately more injury presentations in the hotter and wetter October than in colder and drier April. The most common mechanisms of injury were falls, physical violence and road traffic injuries. Overall, 9.1 % of injury cases were admitted to hospital and 0.2 % died. CONCLUSIONS: Injuries corresponded to around one-quarter of all emergency admissions in urban Mozambique, and were predominantly caused by falls, physical violence, and road traffic injuries. Understanding distinctive variations in the pattern and timing of these presentations according to the age, location and season will assist in future planning for more efficient injury prevention and health care services in Mozambique
Contact Precautions for Preventing Methicillin-Resistant Staphylococcus Aureus in Pediatric Healthcare Settings: Pros, Cons, and Future Actions
No full textAlthough contact precautions (CP) have proven effective in protecting patients and healthcare providers and preventing the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities, pediatric patients under CP may experience unintended effects, including psychosocial stress and limited access to developmentally appropriate activities. Modifying or discontinuing the routine use of CP based on risk assessment results may enhance their overall benefits. Facilities that opt to modify or cease the routine use of CP should base their decisions on (1) compliance with the local regulations related to MRSA; (2) institutional compliance with CP for patients with MRSA infection and/or colonization, and (3) assessment of local MRSA data. Irrespective of any changes, all pediatric facilities should conduct ongoing assessments of MRSA-specific risks and monitor compliance with infection control practices. The results of these activities should guide the optimal use of CP to prevent MRSA infections among hospitalized pediatric patients
Nonprescription Magnesium Supplement Use and Risk of Heart Failure in Patients With Diabetes: A Target Trial Emulation
No full textBACKGROUND: Both diabetes and low magnesium-containing food intake may increase the risk of heart failure (HF). However, the effect of nonprescription magnesium supplements on the risk of HF or major adverse cardiac events in patients with diabetes is unknown. METHODS AND RESULTS: Using a target-trial-emulation approach, we assembled a national cohort of 94 239 veterans ≥40 years with diabetes, without prior HF or magnesium use, who received ambulatory care in the US veterans-health care system documented by electronic clinic notes between January 1, 2006 and December 31, 2020. A natural language processing approach was used to detect self-reported magnesium-supplement use from clinic notes, n=17 619 were identified as users versus n=76 620 as nonusers. Using inverse probability treatment weighting, we constructed a cohort balanced in 88 baseline characteristics between users and nonusers. The primary outcome was incident HF. Secondary outcomes were major adverse cardiac events (myocardial infarction, stroke, HF hospitalization, or death). Hazard ratios (HRs) associated with magnesium-supplement use and outcomes were estimated in the inverse probability treatment weighting weighted cohort using Cox regression. The inverse probability treatment weighting weighted cohort had a mean age of 67.4±10.3 years; 18.4% were Black, and 5.1% were women. The mean duration of magnesium-supplement use was 3.5±3.1 (interquartile range, 1.1-5.1) years. Incident HF occurred in 8.0% of users and 9.7% of nonusers of magnesium supplements (HR, 0.94 [95% CI, 0.89-0.99]). Magnesium-supplement use was also associated with a reduced risk of major adverse cardiac events (HR, 0.94 [95% CI, 0.90-0.97]). CONCLUSIONS: Long-term nonprescription magnesium supplement use was associated with a lower risk of incident HF and major adverse cardiac events in patients with diabetes. These findings should be replicated in randomized controlled trials
Application of cervical spinal motion restriction to injured children in the prehospital setting
No full textOBJECTIVE: Improved data on spinal motion restriction (SMR) use can improve pediatric prehospital guidelines and inform the appropriate use of this procedure. We sought to evaluate the prevalence and factors associated with SMR among injured children in the prehospital setting. METHODS: We performed a retrospective analysis using retrospective data using the 2022-2023 National Emergency Medical Services Information System datasets, including injured pediatric (\u3c18 years) ground encounters at the scene transported to the hospital. We identified the percentage of encounters for which SMR was applied. We identified demographic and clinical associations with SMR application using a linear mixed effects model. RESULTS: We identified 623,785 encounters for injured children (median age 13 years, IQR 6-15; 55.5 % for boys). Among these, 67,551 (10.8 %) had SMR applied in the prehospital setting. In multivariable analysis, SMR use was positively associated (odds ratio, 95 % confidence interval) with older age (1.05, 1.05-1.05), longer transport times (1.23, 1.20-1.25), altered consciousness (increasing odds ratios from 3.12 to 4.54 with worsening AVPU scores), high reported pain scores (1.24, 1.21-1.27 relative to low/medium pain), advanced life support transports (1.81, 1.74-1.88), tachycardia (1.11, 1.06-1.16), tachypnea (1.45, 1.37-1.52), bradypnea (1.15, 1.05-1.26). Hypotension was negatively associated with SMR (0.59, 0.54-0.65). Pedestrian and non-traffic MVCs were positively associated with SMR; mechanisms of falls, penetration with sharp objects, and environmental injuries were negatively associated with SMR. CONCLUSIONS: We identified multiple factors associated with SMR use. These findings provide an opportunity to evaluate practices, track changes, and assess the impact of updated SMR guidelines in pediatric EMS