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Diaphragm dysfunction following surgery for congenital heart disease is a known complication leading to delays in recovery and increased post-operative morbidity and mortality. We aimed to determine the incidence of and risk factors associated with diaphragm plication in children undergoing cardiac surgery and evaluate timing to repair and effects on hospital cost and length of stay.
We conducted a multi-institutional retrospective observational cohort study. Forty-three hospitals from the Pediatric Health Information System database were included, and a total of 112,110 patients admitted between January 2004 and December 2014 were analysed.
Patients less than 18 years of age who underwent cardiac surgery were included. Risk Adjustment for Congenital Heart Surgery was utilized to determine procedure complexity. The overall incidence of diaphragm dysfunction was 2.2% (n = 2513 out of 112,110). Of these, 24.0% (603 patients) underwent diaphragm plication. Higher complexity cardiac surgery (Risk Adjustment for Congenital Heart Surgery 5–6) and age less than 4 weeks were associated with a higher likelihood of diaphragm plication (p-value < 0.01). Diaphragmatic plication was associated with increased hospital length of stay (p-value < 0.01) and increased medical cost.
Diaphragm plication after surgery for congenital heart disease is associated with longer hospital length of stay and increased cost. There is a strong correlation of prolonged time to plication with increased length of stay and medical cost. The likelihood of plication increases with younger age and higher procedure complexity. Methods to improve early recognition and treatment of diaphragm dysfunction should be developed.
Evidence is mixed on e-cigarette's effectiveness as a tobacco cessation aid. Research suggests that e-cigarette users face greater barriers to quitting tobacco.
To examine the association between e-cigarette use and tobacco cessation outcomes among quitline callers.
We examined 2,204 callers who enrolled and completed 7-month follow-up surveys between April 2014 and January 2017. We examined the association between any e-cigarette use and tobacco cessation. We also evaluated these relationships by e-cigarette use patterns between enrollment and 7-month follow-up: sustained, adopted, discontinued, and non-use. We used multivariable logistic regression to control for caller characteristics, tobacco history, and program utilization.
Overall, 18% of callers reported using e-cigarettes at enrollment, follow-up, or both. Compared to non-users, e-cigarette users were more likely to be younger, non-Hispanic, and report a mental health condition. The adjusted odds of tobacco cessation were not statistically different for callers who used e-cigarettes compared to those who did not (adjusted odds ratios = 1.02, 95% confidence interval 0.79–1.32). Results were similar when examining cessation by patterns of e-cigarette use.
E-cigarette use was not associated with tobacco cessation. This suggests that e-cigarette use may neither facilitate nor deter tobacco cessation among quitline callers. Future research should continue exploring how e-cigarette use affects quitting.
This article examines the labour of socialist music in the German Democratic Republic, focusing on composer Paul Dessau's use of political cryptography and quotation in a number of compositions from the opera The Condemnation of Lukullus (1950) through to Choral Music No. 5 (1976). Most famous for his collaborations with Bertolt Brecht, Dessau was the leading avant-garde composer of the GDR and its chief practitioner of serialism. He believed that only difficult, progressive New Music could convey the struggle(s) of socialism. This brought him into conflict with the authorities, who accused him of formalism. Choral Music No. 5 is a setting of a poem by Heiner Müller based on a speech by Erich Honecker (Žižek refers to the text as an ‘obscenity’). Dessau's composition is complex and dialectical, abrasive in its rhythms and counterpoint, and pluralistic in style. It is the embodiment of Dessau's belief in socialist music as rewarding hard work.
Although Bastin et al. propose a useful model for thinking about the structure of memory and memory deficits, their distinction between entities and relational encoding is incompatible with data showing that even individual objects – prototypical “entities” – are made up of distinct features which require binding. Thus, “entity” and “relational” brain regions may need to solve fundamentally the same problems.
The Arizona Department of Health Services identified unusually high levels of influenza activity and severe complications during the 2015–2016 influenza season leading to concerns about potential increased disease severity compared with prior seasons. We estimated state-level burden and severity to compare across three seasons using multiple data sources for community-level illness, hospitalisation and death. Severity ratios were calculated as the number of hospitalisations or deaths per community case. Community influenza-like illness rates, hospitalisation rates and mortality rates in 2015–2016 were higher than the previous two seasons. However, ratios of severe disease to community illness were similar. Arizona experienced overall increased disease burden in 2015–2016, but not increased severity compared with prior seasons. Timely estimates of state-specific burden and severity are potentially feasible and may provide important information during seemingly unusual influenza seasons or pandemic situations.
The effect of tunnel cations on tunnel size in α-MnO2 structured (hollandite, cryptomelane) materials has long been of interest, as the tunnel size effects catalytic and transport properties. Previous research on the tunnel size has focused on potassium cryptomelane (KxMn8O16). This paper uses synthetic control of silver content in AgxMn8O16 to investigate the effect that tunnel silver occupancy has on the lattice parameters. Materials with silver (x) content between 1.14 and 1.66 were synthesized, synchrotron diffraction and Rietveld Refinement was used to determine lattice parameters. The lattice parameters were found to contract as silver content increases (from 9.774 Å to 9.738 Å), in contrast to previous investigations of other tunnel cations.
Few data are available regarding the use of metolazone in infants in cardiac intensive care. Researchers need to carry out further evaluation to characterise the effects of this treatment in this population.
This is a descriptive, retrospective study carried out in patients less than a year old. These infants had received metolazone over a 2-year period in the paediatric cardiac intensive care unit at our institution. The primary goal was to measure the change in urine output from 24 hours before the start of metolazone therapy to 24 hours after. Patient demographic variables, laboratory data, and fluid-balance data were analysed.
The study identified 97 infants with a mean age of 0.32±0.25 years. Their mean weight was 4.9±1.5 kg, and 58% of the participants were male. An overall 63% of them had undergone cardiovascular surgery. The baseline estimated creatinine clearance was 93±37 ml/minute/1.73 m2. Initially, the participants had received a metolazone dose of 0.27±0.10 mg/kg/day, the maximum dose being 0.43 mg/kg/day. They had also received other diuretics during metolazone initiation, such as furosemide (87.6%), spironolactone (58.8%), acetazolamide (11.3%), bumetanide (7.2%), and ethacrynic acid (1%). The median change in urine output after metolazone was 0.9 ml/kg/hour (interquartile range 0.15–1.9). The study categorised a total of 66 patients (68.0%) as responders. Multivariable analysis identified acetazolamide use (p=0.002) and increased fluid input in the 24 hours after metolazone initiation (p<0.001) as being significant for increased urine output. Changes in urine output were not associated with the dose of metolazone (p>0.05).
Metolazone increased urine output in a select group of patients. Efficacy can be maximised by strategic selection of patients.
Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level.
We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient’s autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure.
A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual’s peak autoregulation and biomarker values (p=0.01).
Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.
Sequential nephron blockade using intravenous chlorothiazide is often used to enhance urine output in patients with inadequate response to loop diuretics. A few data exist to support this practice in critically ill infants.
We included 100 consecutive patients <1 year of age who were administered intravenous chlorothiazide while receiving furosemide therapy in the cardiac ICU in our study. The primary end point was change in urine output 24 hours after chlorothiazide administration, and patients were considered to be responders if an increase in urine output of 0.5 ml/kg/hour was documented. Data on demographic, clinical, fluid intake/output, and furosemide and chlorothiazide dosing were collected. Multivariable regression analyses were performed to determine variables significant for increase in urine output after chlorothiazide administration.
The study population was 48% male, with a mean weight of 4.9±1.8 kg, and 69% had undergone previous cardiovascular surgery. Intravenous chlorothiazide was initiated at 89 days (interquartile range 20–127 days) of life at a dose of 4.6±2.7 mg/kg/day (maximum 12 mg/kg/day). Baseline estimated creatinine clearance was 83±42 ml/minute/1.73 m2. Furosemide dose before chlorothiazide administration was 2.8±1.4 mg/kg/day and 3.3±1.5 mg/kg/day after administration. A total of 43% of patients were categorised as responders, and increase in furosemide dose was the only variable significant for increase in urine output on multivariable analysis (p<0.05). No graphical trends were noted for change in urine output and dose of chlorothiazide.
Sequential nephron blockade with intravenous chlorothiazide was not consistently associated with improved urine output in critically ill infants.
This work focused on the modification of milled GaN powder. Successful attachment of a porphyrin derivative to a GaN powder was performed via in situ functionalization in the presence of phosphoric acid. The GaN powder was imaged using scanning electron microscopy and was found to be heterogeneous in nature, adopting no consistent geometry in the aggregates. The aqueous stability of the porphyrin used was observed in deionized water and a solution of phosphoric acid using ultraviolet–visible spectroscopy. Surface chemistry was characterized with x-ray photoelectron spectroscopy and infrared spectroscopy, which identified evidence of successful functionalization through the presence of characteristic peaks. The interface stability of the covalent bond between GaN and porphyrin was evaluated using fluorescence spectroscopy and demonstrated no leaching of dye in water solutions for 20 days.
Serum digoxin levels have limited utility for determining digoxin toxicity in adults. Paediatric data assessing the utility of monitoring serum digoxin concentration are scarce. We sought to determine whether serum digoxin concentrations are associated with signs and symptoms of digoxin toxicity in children.
We carried out a retrospective review of patients <19 years of age who received digoxin and had serum digoxin concentrations assessed between January, 2007 and June, 2013. Data collection included patient demographics, digoxin indication, serum digoxin concentrations, signs and symptoms of digoxin toxicity, electrocardiograms, and co-morbidities. Reviewers performing chart review and electrocardiogram analysis were blinded to digoxin levels. Descriptive statistical methods were used and comparisons were made between patients with and without toxic serum digoxin concentrations (>2 ng/ml).
There were 87 patients who met study criteria (male 46%, mean age 8.4 years). CHD was present in 67.8% and electrocardiograms were performed in 72.4% of the patients. The most common indication for digoxin toxicity was heart failure symptoms (61.5%). Toxic serum digoxin concentrations were present in 6.9% of patients (mean 2.6 ng/ml). Symptoms associated with digoxin toxicity occurred in 48.4%, with nausea/vomiting as the most common symptom (36.4%), followed by tachycardia (29.5%). Compared with those without toxic serum digoxin concentrations, significantly more patients with toxic serum digoxin concentrations were female (p=0.02). The presence of electrocardiogram abnormalities and/or signs and symptoms of digoxin toxicity was not significantly different between patients with and without serum digoxin concentrations (p>0.05).
Serum digoxin concentrations in children are not strongly associated with signs and symptoms of digoxin toxicity.
Introduction: Digoxin or propranolol are used as first-line enteral agents for treatment of infant supraventricular tachycardia. We used a large national database to determine whether enteral digoxin or propranolol was more effciacious as first-line infant supraventricular tachycardia therapy. Materials and Methods: The Pediatric Health Information System database was queried over 10 years for infants with supraventricular tachycardia initiated on enteral digoxin or propranolol monotherapy. Patients were excluded for Wolff–Parkinson–White, intravenous antiarrhythmics (other than adenosine), or death. Success was considered as discharge on the initiated monotherapy. Risk factors for successful monotherapy and risk factors for readmission for supraventricular tachycardia for patients discharged on monotherapy were determined. Results: A total of 374 patients (59.6% male) met the study criteria. Median length of stay was 7 days (interquartile range of 3–16 days). Patients had CHD (n=199, 53.2%) and underwent cardiac surgery (n=123, 32.9%), ICU admission (n=238, 63.6%), mechanical ventilation (n=146, 39.0%), and extracorporeal membrane oxygenation (n=3, 0.8%). Pharmacotherapy initiation was at median 37 days of life (interquartile range of 12–127 days) and 47.3% were initiated on digoxin. Success was similar between digoxin (73.1%) and propranolol (73.5%). Initial therapy with digoxin was not associated with success (odds ratio 1.01, 95% CI 0.64–1.61, p=0.93). Multivariable analysis demonstrated hospital length of stay (odds ratio 0.98, 95% CI 0.98–1.00) and involvement of a paediatric cardiologist (odds ratio 0.46, 95% CI 0.29–0.75) associated with monotherapy failure, and male gender (odds ratio 1.66, 95% CI 1.03–2.67) associated with monotherapy success. No variables were significant for readmission on multivariable analysis. Discussion: Digoxin or propranolol may be equally efficacious for inpatient treatment of infant supraventricular tachycardia.
Introduction: The diagnosis of trisomy 21 in children has been associated with failed extubation after CHD surgery. Dexmedetomidine may be a useful agent to improve postoperative outcomes in these patients, such as ventilator time, ICU length of stay, or hospital length of stay. Materials and methods: The Pediatric Health Information System database was queried from January, 2008 to December, 2010 for patients with trisomy 21 who underwent CHD surgery. Patients who received dexmedetomidine were matched to patients who did not by propensity score. The primary outcome was ventilator days charged, and secondary outcomes included ICU and hospital length of stay. Results: A total of 1088 patients (544 matched pairs) met inclusion criteria. Patient characteristics were similar, with the exception of more patients in the dexmedetomidine group undergoing repair of complete atrioventricular canal and fewer undergoing mechanical valve replacement (p<0.01). More patients in the dexmedetomidine group were administered milrinone, epinephrine, vasopressin, benzodiazepines, opiates, and adjunct pain and sedative medications (p<0.01). The dexmedetomidine group had greater time on the ventilator [7 (4.5–11) versus 6 (4–10) days (median, interquartile range) p<0.01] and similar ICU length of stay, hospital length of stay, and mortality compared with controls. Mixed-effects modelling clustered on institution did not show beneficial effect of dexmedetomidine on ventilator time, ICU stay, or hospital length of stay. Conclusions: The use of dexmedetomidine was not associated with the decreased ventilatory time. Routine use of dexmedetomidine is not warranted in this patient population.