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RationaleLittle is known on the use of noninvasive ventilation (NIPPV) in pediatric hematopoietic cell transplant (HCT) patients.ObjectiveWe sought to describe the landscape of NIPPV use and to identify risk factors for failure to inform future investigation or quality improvement.MethodsThis is a multicenter, retrospective observational cohort of 153 consecutive children post-HCT requiring NIPPV from 2010-2016.Results97 (63%) failed NIPPV. Factors associated with failure on univariate analysis included: longer oxygen use prior to NIPPV (p=0.04), vasoactive agent use (p40 at 4 hours [aOR=6.3 9(95% CI: 2.4, 16.4), p

The cavernous sinus is a complex anatomical space with multiple neuro-vascular structures. Due to its anatomical complexity, patients with internal carotid artery aneurysms within the cavernous sinus can present with a variety of symptoms. This is a case presentation of a 73-year-old patient with a right-sided intracavernous internal carotid artery aneurysm who declined neurosurgical intervention, opting for conservative management. The evolution of symptoms is highlighted, from intermittent changes in vision to further development of proptosis, associated with the reduction of vision, Horner’s syndrome, sixth nerve palsy, and disc swelling. This culminated in a severe reduction in vision due to optic atrophy, restriction of eye movements with maintained adduction only, dilatation of the pupil, and forehead/cheek hypoesthesia. [ABSTRACT FROM AUTHOR]

Introduction: There is a high prevalence of sleep disturbances and disorders such as obstructive sleep apnea (OSA) in children with attention-deficit hyperactivity disorder (ADHD), though this relationship remains poorly characterized by objective measures. Polysomnographic studies (PSGs) on sleep disruptions in ADHD have yielded inconsistent results. Few have studied polysomnograms in stimulant-medicated vs. non-medicated children with ADHD+/-OSA. This study aimed to elucidate pathognomonic polysomnographic sleep disturbances in children diagnosed with ADHD+/-OSA. Methods: Medical charts and polysomnograms were retrospectively reviewed for children ages 4-18 who underwent overnight polysomnography at a tertiary care center from 2019 to 2022. ADHD diagnosis was determined by ICD code F90, andOSA was defined by apnea-hypopnea indices (AHI)≥5 events/hour. Four groups were evaluated: children without OSA or ADHD, children with OSA alone, children with ADHD alone, and children with ADHD+OSA. Statistical analyses identified significant differences among variables of interest. Results: 4,013 children met the study criteria. 2,372 children were without OSA and without ADHD (59.1%), 1,197 with OSA alone (29.8%), 333 with ADHD alone (8.3%), and 111 with ADHD and OSA (2.8%). Insomnia (ICD code G47.00) was prevalent in children with ADHD alone. However, they exhibited significantly better sleep efficiency (SE), than children with OSA alone, and SE did not significantly differ from the other groups. No significant difference in periodic limbmovements (PLMs) was found across all groups. The above results held true even after correcting for stimulant prescription. Conclusion: The increased frequency of clinical insomnia diagnoses in children with ADHD is not associated with any traditional parameters on polysomnogram. Innovative subclinical polysomnographic biomarkers are needed to identify sleep characteristics unique to ADHD. In children with both ADHDandOSA, PSG results do not reveal any distinctive sleep disturbances which cannot be better explained by OSA alone. These findings underscore the importance of screening for OSA in patients with ADHD and clinically assessing for other sleep concerns. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the utilization of drugs with pharmacogenomic guidelines (PGx-drugs) for personalized dosing in pediatric leukemia. A retrospective observational study of pediatric leukemia patients admitted between 2009–2019 at a single-center academic children's hospital was conducted to determine PGx-drug exposure within 3 years of diagnosis. Along with baseline demographic and clinical characteristics of these patients, data regarding dates of diagnosis, relapse, death were collected. During the study period, inclusion criteria were met by 714 patients. The most frequently given medications were ondansetron (96.1%), morphine (92.2%), and allopurinol (85.3%) during the study period. In this cohort, 82% of patients received five or more PGx-drugs. Patients diagnosed with acute myeloid leukemia and leukemia unspecified were prescribed more PGx-drugs than other types of leukemia. There was a significant relationship between age at diagnosis and the number of PGx-drugs prescribed. Adolescents and adults both received a median of 10 PGx-drugs, children received a median of 6 PGx-drugs, and infants received a median of 7 PGx-drugs (p < 0.001). Patients with recurrent leukemia had significantly more PGx-drugs prescribed compared to those without recurrent disease, 10 drugs and 6 drugs, respectively (p < 0.001). Patients diagnosed with childhood leukemia are high utilizers of PGx-drugs. There is a vital need to understand how PGx testing may be utilized to optimize treatment and enhance quality of life. Preemptive PGx testing is a tool that aids in optimization of drug therapy and decreases the need for later treatment modifications. This can result in financial savings from decreased health-care encounters. [ABSTRACT FROM AUTHOR]

Moral distress is a well-documented phenomenon for health care providers (HCPs). Exploring HCPs' perceptions of participation in moral distress interventions using qualitative and quantitative methods enhances understanding of intervention effectiveness. The purpose of this study was to measure and describe the impact of a two-phased intervention on participants' moral distress. Using a cross-over design, the project aimed to determine if the intervention would decrease moral distress, enhance moral agency, and improve perceptions about the work environment. We used quantitative instruments and explored participants' perceptions of the intervention using semi-structured interviews. Participants were from inpatient settings, within three major hospitals of a large, urban healthcare system in the Midwest, United States. Participants included nurses (80.6%) and other clinical care providers. Using generalized linear mixed modeling we assessed the change in each of the outcome variables over time controlling for groups. Interviews were audiotaped and professionally transcribed. The written narratives were coded into themes. The change in scores on study instruments trended in the desired direction however did not meet statistical significance. Qualitative interviews revealed that intervention effectiveness was derived from a combination of learning benefits, psychological benefits, and building community that promoted moral agency. Findings demonstrate a clear link between moral distress and moral agency and suggest that Facilitated Ethics Conversations can enhance the work environment. Findings provide insight for developing evidenced-based approaches to address moral distress of hospital nurses. [ABSTRACT FROM AUTHOR]

BackgroundIn 2014, Joint Commission recommended palliative care (PC) engagement in ventricular assist device (VAD) implantation as destination therapy. Limited information is available on established PC protocols in the mechanical circulatory support (MCS) population.MeasuresThe goals of our PC consultation were to document advance care planning (ACP) discussions and designate a surrogate decision maker (SDM) before MCS implantation. A retrospective analysis compared the frequency of PC consults, ACP discussion, and SDM before and after protocol implementation.InterventionA protocol was developed to conduct interdisciplinary PC consultations for the MCS population.OutcomesThe percentage of PC consults placed before MCS implantation increased from 11 (17.2%) before protocol to 56 (96.6%) after protocol (P

Humans living at high-altitude (HA) have adapted to this environment by increasing pulmonary vascular and alveolar growth. RNA sequencing data from a novel murine model that mimics this phenotypical response to HA suggested estrogen signaling via estrogen receptor alpha (ERα) may be involved in this adaptation. We hypothesized ERα was a key mediator in the cardiopulmonary adaptation to chronic hypoxia and sought to delineate the mechanistic role ERα contributes to this process by exposing novel loss-of-function ERα mutant (ERαMut) rats to simulated HA. ERα mutant or wild-type (wt) rats were exposed to normoxia or hypoxia starting at conception and continued postnatally until 6 wk of age. Both wt and ERαMut animals born and raised in hypoxia exhibited lower body mass and higher hematocrits, total alveolar volumes (Va), diffusion capacities of carbon monoxide (DLCO), pulmonary arteriole (PA) wall thickness, and Fulton indices than normoxia animals. Right ventricle adaptation was maintained in the setting of hypoxia. Although no major physiologic differences were seen between wt and ERαMut animals at either exposure, ERαMut animals exhibited smaller mean linear intercepts (MLI) and increased PA total and lumen areas. Hypoxia exposure or ERα loss-of-function did not affect lung mRNA abundance of vascular endothelial growth factor, angiopoietin 2, or apelin. Sexual dimorphisms were noted in PA wall thickness and PA lumen area in ERαMut rats. In summary, in room air-exposed rats and rats with peri- and postnatal hypoxia exposure, ERα loss-of-function was associated with decreased alveolar size (primarily driven by hypoxic animals) and increased PA remodeling. NEW & NOTEWORTHY By exposing novel loss-of-function estrogen receptor alpha (Erα) mutant rats to a novel model of human high-altitude exposure, we demonstrate that ERα has subtle but inconsistent effects on endpoints relevant to cardiopulmonary adaptation to chronic hypoxia. Given that we observed some histologic, sex, and genotype differences, further research into cell-specific effects of ERα during hypoxia-induced cardiopulmonary adaptation is warranted. [ABSTRACT FROM AUTHOR]

Objective Bronchopulmonary dysplasia (BPD) is a major cause of morbidity in neonates and can be associated with long hospitalization and high health care utilization. This extremely stressful situation can be difficult for many families and caregivers. The high-risk situation combined with increased medical complexity can result in involvement of Department of Child Services (DCS) and even foster care placement. This study seeks to define risk factors for DCS involvement and foster care placement in children with BPD. Study Design A retrospective study of children born at less than 32 weeks of gestation born between 2010 and 2016, on oxygen at 28 days of life and discharged home from a tertiary care center. Results A total of 246 patients were identified. DCS was involved in 49 patients with 13 requiring foster care placement. The most common correlated risk factors that were identified for DCS involvement were maternal THC (tetrahydrocannabinol) positivity, hospital policy violations, maternal mental health diagnosis, and home insecurity. Home insecurity (p < 0.005) and amphetamine use (p < 0.005) were associated with foster care placement. Conclusion There are numerous risk factors for both DCS and foster care placement. The identification of these risk factors is important to help establish services to help families and identify potential biases to avoid. Key Points There were both substance-related and non-substance-related risk factors for DCS involvement. Home insecurity and maternal amphetamine use were risk factors associated with foster care placement. This study fills the knowledge gap of risk factors for DCS and foster care placement in BPD. [ABSTRACT FROM AUTHOR]