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To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery.
Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models.
Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65–0.86) compared to 0.617 (95% confidence interval: 0.47–0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72–0.89; p-value: 0.003).
Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
Introduction: The harm that may come to healthcare providers impacted by adverse events has led them to be called “second victims.” Our objective was to characterize the range and context of interventions used to support second victims in acute care settings. Methods: We performed a scoping study using the process described by Arksey and O'Malley. Comprehensive searches of scientific databases and grey literature were conducted in September 2017 and updated in November 2018. A library scientist searched PubMed, CINAHL, EMBASE and CENTRAL. We sought unpublished literature (Canadian Electronic Library, Proquest and Scopus) and searched reference lists of included studies. Stakeholder organizations and authors of included studies were contacted through email, requesting information on relevant programs. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data and appraised methodological quality with the Mixed Methods Appraisal Tool (MMAT). All discrepancies were resolved through consensus. A qualitative approach was used to categorize the context and characteristics of the identified strategies and interventions. Results: Our search strategy yielded 3883 results. After screening titles and abstracts, 173 studies underwent full text screening. Extracted data reflected 21 interventions categorized as providing peer-support (n = 7), proactive education (n = 7) or both (n = 7). Programs came from Canada (n = 2), Spain (n = 2), and United States (n = 17). Specific traumatic events were described as the trigger for development of five programs. While some programs were confined to a standard definition of second victim as a healthcare provider traumatized by an “unanticipated adverse patient event” (n = 6), other programs had a broader scope (n = 12) including situations such as non-accidental trauma, stressful anticipated patient events and complaints/litigation (3 programs were unclear about the definition). Confidentiality was assured in nine peer support programs. Outcome measures were often not reported and were limited in terms of quality. Conclusion: This is a new area of study with little scientific rigour from which to determine whether these programs are effective. Concerns about protecting healthcare providers from potential legal proceedings hinder documentation and study of program effectiveness.
Rayleigh–Bénard convection is one of the most well-studied models in fluid mechanics. Atmospheric convection, one of the most important components of the climate system, is by comparison complicated and poorly understood. A key attribute of atmospheric convection is the buoyancy source provided by the condensation of water vapour, but the presence of radiation, compressibility, liquid water and ice further complicate the system and our understanding of it. In this paper we present an idealized model of moist convection by taking the Boussinesq limit of the ideal-gas equations and adding a condensate that obeys a simplified Clausius–Clapeyron relation. The system allows moist convection to be explored at a fundamental level and reduces to the classical Rayleigh–Bénard model if the latent heat of condensation is taken to be zero. The model has an exact, Rayleigh-number-independent ‘drizzle’ solution in which the diffusion of water vapour from a saturated lower surface is balanced by condensation, with the temperature field (and so the saturation value of the moisture) determined self-consistently by the heat released in the condensation. This state is the moist analogue of the conductive solution in the classical problem. We numerically determine the linear stability properties of this solution as a function of Rayleigh number and a non-dimensional latent-heat parameter. We also present some two-dimensional, time-dependent, nonlinear solutions at various values of Rayleigh number and the non-dimensional condensational parameters. At sufficiently low Rayleigh number the system converges to the drizzle solution, and we find no evidence that two-dimensional self-sustained convection can occur when that solution is stable. The flow transitions from steady to turbulent as the Rayleigh number or the effects of condensation are increased, with plumes triggered by gravity waves emanating from other plumes. The interior dries as the level of turbulence increases, because the plumes entrain more dry air and because the saturated boundary layer at the top becomes thinner. The flow develops a broad relative humidity minimum in the domain interior, only weakly dependent on Rayleigh number when that is high.
We observed pediatric S. aureus hospitalizations decreased 36% from 26.3 to 16.8 infections per 1,000 admissions from 2009 to 2016, with methicillin-resistant S. aureus (MRSA) decreasing by 52% and methicillin-susceptible S. aureus decreasing by 17%, among 39 pediatric hospitals. Similar decreases were observed for days of therapy of anti-MRSA antibiotics.
The triazines are one of the most widely used herbicide classes ever developed and are critical for managing weed populations that have developed herbicide resistance. These herbicides are traditionally valued for their residual weed control in more than 50 crops. Scientific literature suggests that atrazine, and perhaps other s-triazines, may no longer remain persistent in soils due to enhanced microbial degradation. Experiments examined the rate of degradation of atrazine and two other triazine herbicides, simazine and metribuzin, in both atrazine-adapted and non-history Corn Belt soils, with similar soils being used from each state as a comparison of potential triazine degradation. In three soils with no history of atrazine use, the t1/2 of atrazine was at least four times greater than in three soils with a history of atrazine use. Simazine degradation in the same three sets of soils was 2.4 to 15 times more rapid in history soils than non-history soils. Metribuzin in history soils degraded at 0.6, 0.9, and 1.9 times the rate seen in the same three non-history soils. These results indicate enhanced degradation of the symmetrical triazine simazine, but not of the asymmetrical triazine metribuzin.
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.