Explore the vast range of titles available.

ObjectivesTo evaluate risk factors associated with eye injuries related to motor vehicle accidents (MVA) using a multicentre national database from the US emergency departments.Patients and methodsA post hoc analysis from the Nationwide Emergency Department Sample database (2006–2013) was performed. Patients presenting to the emergency department (ED) with MVA-related trauma were included. We then evaluated patient- and centre-level risk factors associated with the presence of ocular trauma using a multivariable logistic regression model.ResultsA total of 2,745,152 patients from 2080 ED were identified for inclusion. Of these, 31,493 patients (1.14%) were associated with ocular trauma. The most common ocular injuries reported in our study were injury to ocular adnexa, orbital fractures, subconjunctival haemorrhage, foreign body on eye, and open wound of the eyeball. In univariate analysis, the other patient factors associated with ocular trauma included male gender, >1 chronic condition, admission during weekend, >1 bodily injury, higher injury severity score (ISS), presence of skull fractures and other bodily fractures, seizures, and initiation of mechanical ventilation after MVA. The hospital characteristics associated with highest incidence of ocular trauma included ED visit to a level I trauma centre and metropolitan teaching hospital. The independent factors associated with ocular trauma included younger age groups, male gender, weekend injury, presence of chronic conditions, >1 bodily injury, higher ISS, presence of skull fractures, ED admission to level-1 trauma centre, and ED admission to a teaching hospital.ConclusionsThis multicentre study establishes that both patient- and centre-level factors are associated with MVA-related eye injuries.

Abstract Rationale The around-the-clock presence of an in-house attending critical care physician (24/7 coverage) is purported to be associated with improved outcomes among high-risk children with critical illness. Objectives To evaluate the association of 24/7 in-house coverage with outcomes in children with critical illness. Methods Patients younger than 18 years of age in the Virtual Pediatric Systems Database (2009–2014) were included. The main analysis was performed using generalized linear mixed effects multivariable regression models. In addition, multiple sensitivity analyses were performed to test the robustness of our findings. Measurements and Main Results A total of 455,607 patients from 125 hospitals were included (24/7 group: 266,319 patients; no 24/7 group: 189,288 patients). After adjusting for patient and center characteristics, the 24/7 group was associated with lower mortality in the intensive care unit (ICU) (24/7 vs. no 24/7; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33–0.80; P = 0.002), a lower incidence of cardiac arrest (OR, 0.73; 95% CI, 0.54–0.99; P = 0.04), lower mortality after cardiac arrest (OR, 0.56; 95% CI, 0.340–0.93; P = 0.02), a shorter ICU stay (mean difference, −0.51 d; 95% CI, −0.93 to −0.09), and shorter duration of mechanical ventilation (mean difference, −0.68 d; 95% CI, −1.23 to −0.14). Conclusions In this large observational study, we demonstrated that pediatric critical care provided in the ICUs staffed with a 24/7 intensivist presence is associated with improved overall patient survival and survival after cardiac arrest compared with patients treated in ICUs staffed with discretionary attending coverage. However, results from a few sensitivity analyses leave some ambiguity in these results.

Background : The existing training pathways to become a pediatric cardiac intensivist are very variable with physicians coming from varied training backgrounds of pediatric critical care, pediatric cardiology, neonatology, or pediatric anesthesia. Aim : To evaluate the impact of cardiac Intensive Care Unit (ICU) attending physician training background on outcomes in children undergoing heart operations. Setting and Design : Patients in the age group from 1 day to 18 years undergoing heart operation at a Pediatric Health Information System database participating hospital were included (2010-2015). Patients and Methods : Based on the training background of majority of attending physicians in an ICU, the participating ICUs were divided into three groups: critical care medicine (CCM), cardiology, and indeterminate. Statistical Analysis : Multivariable logistic regression models were fitted to evaluate the association of ICU physician training background with study outcomes. Results : A total of 54,935 patients from 42 ICUs were included. Of these, 31,815 patients (58%) were treated in the CCM group (26 ICUs), 19,340 patients (35%) were treated in the cardiology group (12 ICUs), and 3780 patients (7%) were treated in the indeterminate group (4 ICUs). In adjusted models, no specific group based on ICU attending physician training background was associated with lower mortality (CCM vs. cardiology, odds ratio: 0.75, 95% confidence interval: 0.48-1.18), or lower incidence of cardiac arrest, or prolonged hospital length of stay, or prolonged mechanical ventilation. Conclusions : This large observational study did not demonstrate any impact of ICU attending training background on outcomes in children undergoing heart operations.

To study the volume–outcome relationship among children receiving extracorporeal membrane oxygenation (ECMO), different studies from different databases use different volume categories. The objective of this study was to evaluate if different center volume categories impact the volume–outcome relationship among children receiving ECMO for heart operations. We performed a post hoc analysis of data from an existing national database, the Pediatric Health Information System. Centers were classified into five different volume categories using different cut-offs and different variables. Mortality rates were compared between the varied volume categories using a mixed effects logistic regression model after adjusting for patient- and center-level risk factors. Data collection included demographic information, baseline characteristics, pre-ECMO risk factors, operation details, patient diagnoses, and center data. In unadjusted analysis, there was a significant relationship between center volume and mortality, with low-and medium-volume centers associated with higher mortality rates compared to high-volume centers in all volume categories, except the hierarchical clustering volume category. In contrast, there was no significant association between center-volume and mortality among all volume categories in adjusted analysis. We concluded that high-volume centers were not associated with improved outcomes for the majority of the categorization schemes despite using different cut-offs and different variables for volume categorization.

The impact of varied cardiac physiologies on intraocular pressure (IOP) among children undergoing heart operations is unknown. The aim of this study was to determine the IOP among children with varying cardiovascular physiologies and varying hemodynamics after their heart operation. This was a prospective, observational study. Patients ≤18 years undergoing congenital heart surgery were included in this study. IOP measurement was performed by Icare® tonometer between 3 and 14 days after heart operation. Summary statistics were estimated for all demographic, anthropometric, and clinical data. A total of 116 eyes from 58 children were included. The mean and standard deviation age was 28.4 (45.8) months. Single-ventricle anatomy was present in 26 patients (45%). Despite similar heart rate and blood pressure, the mean IOP among the patients with single-ventricle anatomy was significantly elevated as compared to patients with two-ventricle anatomy (18 mm Hg vs. 12 mm Hg, < 0.001). There was no difference in IOP measurements based on the complexity of operation performed. We noted that patients undergoing surgical palliation with central shunt (21 mm Hg), Fontan operation (19 mm Hg), bidirectional Glenn operation (19 mm Hg), Norwood operation (19 mm Hg), or definitive repairs such as tetralogy of Fallot repair (17 mm Hg), and atrioventricular canal repair (19 mm Hg) were associated with the highest IOPs in the study cohort. This study demonstrates that IOPs vary with varying cardiovascular physiology after pediatric cardiac surgery.

Williams syndrome is a complex syndrome characterized by developmental abnormalities, craniofacial dysmorphic features, and cardiac anomalies. Sudden death has been described as a very common complication associated with anesthesia, surgery, and procedures in this population. Anatomical abnormalities associated with the heart pre-dispose these individuals to sudden death. In addition to a sudden and rapid downhill course, lack of response to resuscitation is another significant feature seen in these patients. The authors report a five-year-old male with Williams syndrome, hypothyroidism, and attention deficit hyperactivity disorder. He suffered an anaphylactic reaction during CT imaging with contrast. Resuscitation was unsuccessful. Previous reports regarding the anesthetic management of patients with Williams are reviewed and the potential for sudden death or peri-procedure related cardiac arrest discussed in this report. The authors also review reasons for refractoriness to defined resuscitation guidelines in this patient population.

Background The primary objective of this investigation was to study the association between renal replacement therapy (RRT) and outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Methods Patients aged ≤18 years receiving ECMO before or after a pediatric heart operation at a Pediatric Health Information System (PHIS)-participating hospital (2004–2013) were included. The associations between RRT and study outcomes were computed using multivariate logistic regression analysis. Results A total of 3,502 patients from 43 hospitals qualified for inclusion. Of these, 484 (14 %) patients received RRT at some point during their hospital stay. After adjusting for patient and center characteristics, the odds of mortality were significantly higher in the RRT group (OR: 1.86, 95 % CI: 1.46- 2.37, p < 0.0001). However, there were considerable reductions in adjusted odds of mortality, compared to unadjusted odds of mortality. In adjusted models, length of ECMO was longer by 0.81 days (95 % CI: 0.13- 1.49, p = 0.02) in patients receiving RRT. Conclusions We demonstrated worsening outcomes in children receiving ECMO with RRT compared to children receiving ECMO without RRT. Although the results could reflect confounding by severity of illness, they provide a rationale for prospective testing of use of RRT in critically ill children receiving ECMO with heart surgery.

Historically, the neuron has been the conceptual focus for almost all of neuroscience research. In recent years, however, the concept of the neurovascular unit has emerged as a new paradigm for investigating both physiology and pathology in the CNS. This concept proposes that a purely neurocentric focus is not sufficient, and emphasizes that all cell types in the brain including neuronal, glial and vascular components, must be examined in an integrated context. Cell-cell signaling and coupling between these different compartments form the basis for normal function. Disordered signaling and perturbed coupling form the basis for dysfunction and disease. In this mini-review, we will survey four examples of this phenomenon: hemodynamic neurovascular coupling linking blood flow to brain activity; cellular communications that evoke the blood-brain barrier phenotype; parallel systems that underlie both neurogenesis and angiogenesis in the CNS; and finally, the potential exchange of trophic factors that may link neuronal, glial and vascular homeostasis.

Adenovirus infections mimic bacterial infections on initial presentation in healthy children, leading to higher likelihood of hospital admission. The objective of this study was to identify risk factors associated with hospital admission in previously healthy children with adenovirus infection. This is a retrospective study of 125 previously healthy children, who tested positive with direct immunofluorescence assay (DFA) for adenoviral infection at our center between January 2001 and October 2007. The primary outcome of the study was the need for hospital admission. The relationship between clinical variables at initial emergency room (ER) presentation and need for hospital admission were explored using univariate and multivariate logistic regression models. The model's predictive value was investigated by calculating the area under the receiver operating characteristic (ROC) curve and Hosmer-Lemeshow test. On stepwise multivariate logistic regression analysis, the presence of respiratory distress (odds ratio [OR]: 5.6; p = 0.014), acute gastroenteritis (OR: 3.8; p = 0.019) and wheezes at initial presentation (OR: 6.5; p = 0.003) at the time of initial presentation in the ER were associated with need for hospital admission. For this model, the area under the ROC curve was 0.79, and there was no evidence of lack of fit on Hosmer-Lemeshow goodness-of-fit test (p = 0.56). Our study identifies three risk factors, namely, respiratory distress, wheezing and acute gastroenteritis, associated with hospital admission for healthy children with adenoviral infections.