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Background Management of pediatric pulmonary hypertension (PH) may require manipulation of multiple receptor sites to maximize response to medical therapy. Assessment of response typically occurs through imaging, labs, physical exam and recurrent cardiac catheterization, with anesthetic exposure to assess pulmonary artery pressures (PAP) and vascular resistance (PVR). We aimed to assess feasibility, safety and utility of remote PAP monitoring in pediatric PH patients. Methods We reviewed 4 pediatric patients with significant PH, each of whom underwent cardiac catheterization with pulmonary vasoreactivity testing and placement of a CardioMEMS remote PAP monitoring device. Results Four patients (P1-4: ages 5, 6, 8 and 10 years old) underwent CardioMEMS insertion without procedural complication. P1, P2 and P3 presented with unrepaired VSD;ASD with partial anomalous pulmonary venous return;and ASD and PDA, respectively, while P4 had prior repair of atrioventricular canal. Three patients had Down syndrome. All had elevated PAP and PVR. Mean left lower PA branch size was 7 mm. Mean PAP prior to therapy was 70 mm Hg for P1, 82 for P2, 93 for P3 and 30 for P4. All 4 patients required initiation of triple therapy for treatment of PH, with improvement or normalization of PAP by CardioMEMS, which also included surgical or catheter based intervention for 3 patients. Post-repair of P2, he was unable to be separated from cardiopulmonary bypass and was placed on ECMO. Right ventricular cardiac output improved over 2 weeks, with improvement of PAP determined through serial CardioMEMS. He was successfully decannulated, utilizing CardioMEMS in the OR. Two patients also developed COVID respiratory infections at home with CardioMEMS assessments allowing for oxygen and medication titration. Conclusion Remote PAP monitoring is feasible and appears safe in pediatric patients with adequate PA size. It allows for manipulation of medical therapy with real time knowledge of impact on PAP and can augment management during weaning of mechanical cardiac support. It may also augment decision-making in management of PH patients with developmental disabilities in whom traditional assessments may be more challenging.Copyright © 2023 American College of Cardiology Foundation
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Background Patients with hypoplastic left heart syndrome (HLHS) undergo a Fontan procedure as part of single ventricle surgical palliation. Post-Fontan, sluggish blood flow and an imbalance in coagulant factor proteins may predispose to thrombus formation. Other risk factors may include chylothorax as well as acute and chronic inflammation. Currently, there is no standardized surveillance strategy to detect thrombus in Fontan patients. Case A 34-month old male with HLHS underwent an extracardiac non-fenestrated Fontan complicated by chylothorax treated with 5 days of IV steroids and diuretics. He was on therapeutic aspirin. After progressive worsening of right pleural effusion, a chest tube was placed three weeks post-Fontan with continued chylous output. Stool alpha 1 antitrypsin was negative. Decision-making Given persistent chylothorax, a repeat echocardiogram was performed revealing a large mass in the Fontan circuit less than one month post-op. Cardiac CT showed occlusive thrombus filling the entirety of the Fontan conduit extending into hepatic veins and bilateral pulmonary arteries. He underwent extensive surgical thrombectomy and Fontan conduit revision. Hypercoagulable work-up revealed elevated factor 8 and von Willebrand factor activity which persisted more than one month post-op. Patient's history was also significant for COVID-19 infection 6 months prior. He was initially anticoagulated with bivalirudin with tirofiban initiated for antiplatelet therapy. He was ultimately transitioned to rivaroxaban, pentoxifylline and aspirin with chylothorax resolution over one month without thrombus recurrence. Conclusion Development of risk stratification tools to identify patients at higher risk for thrombi formation post-Fontan may facilitate patient selection for more aggressive anticoagulation. Consideration of elevated factor 8 as well as persistent or recurrent chylothorax may be beneficial, as increased thrombosis risk has been reported for both conditions in Fontan patients.Copyright © 2023 American College of Cardiology Foundation
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Choledochal cysts are rare cystic dilations of the biliary tree that typically involve the extrahepatic bile duct and more infrequently, the intrahepatic bile ducts. Todani's classification of choledochal cysts is the most referenced system in which five types of choledochal cysts are described. Several new variants have been reported including dilations of the cystic duct and a double common bile duct. We describe a never reported variant involving dilation of the common bile duct, dilation of the cystic duct and an accessory right hepatic duct. Copyright © 2022 The Authors
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Purpose: Once the COVID-19 pandemic was declared, clinicians were redeployed to prepare for increased hospitalizations. This disruption necessitated rapid continuing professional development (CPD) resources for health care providers.. This mixed-method study explored the experiences of occupational therapists and physiotherapists who accessed a CPD Web site that provided educational resources related to the pandemic to refresh their clinical knowledge and skills. Methods: Faculty from the Michener Institute of Education at the University Health Network and University of Toronto along with 60 collaborators created a Web site to support the need for rapid CPD. An occupational therapist and physiotherapist advisory group informed the evolving design of the occupational therapy and physiotherapy content. Results: In the occupational therapy profession 535 users created an account between April and November 2020 (236 practicing, 283 students, and 16 did not specify) and in the physiotherapy profession 829 created an account (532 practicing, 278 students and 19 did not specify). Each user viewed an average of 53 Web pages. Three themes emerged: (1)To prepare for practice changes, clinicians value a single repository of information;(2) Web site features can either facilitate or hinder access to the needed information;and (3) Participants described diverse learning needs. Conclusions:The Web site design features assisted participants in preparing for redeployment and patient care. Features to encourage self-directed learning, such as the grouping of relevant topics and self-check quizzes, can enhance the user experience.
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Methods: This cross-sectional study recruited 314 nurses from two hospitals in the southeastern US. Measures were collected via an online survey after IRB approval and informed consent. The Copenhagen Burnout Inventory was used to measure burnout. Multiple choice questions from the survey inquired about preferred stress management strategies (e.g., exercise class, relaxation). Results: Participants were predominantly female, white, married, average age of 40.45 years, and 59% provided direct COVID-19 care. Average burnout score was 59.52 (SD = 19.00);70.9% reported moderate (47.1%) to high/severe (23.8%) burnout. Nurses indicated most interest in “restorative breaks at work” (53.8%), relaxation exercises (52.5%), music therapy (48.7%), exercise (48.1%), yoga (36.6%) and meditation (36.3%) to help manage stress. Logistic regression results showed that nurses' preferences were mostly independent of their levels of burnout (p > .05). Burnout was predictive of choosing restorative breaks (p = .021), meditation (p = .040), and nurses with higher burnout being more likely to choose restorative breaks (OR = 1.02), but less likely to prefer meditation (OR = .99). Background: Burnout is a protracted response to stressors at work, characterized by exhaustion and inadequacy1. During the COVID-19 pandemic, nurses' concerns leading to burnout include lack of resources, rapidly changing advice about the pandemic, and lack of organizational preparedness2. There is a need for interventions to reduce pandemic-related burnout3. This study explores the relationship between levels of burnout and nurses' preference for stress management strategies. This is a partial report of a larger study on COVID-19 stress in nurses. Conclusion: Frontline nurses experience significant burnout levels that warrant intervention. Nurses' top stress management preferences included organizational and individual strategies but were mostly independent of levels of burnout. Results highlight the need for restorative breaks at work, especially for those with higher levels of burnout.
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Keywords: Virtual;Pain;Covid-19 Purpose: Due to the Covid-19 crisis, face-to-face groups were cancelled in the fife pain management service (FPMS) for an indefinite period. This resulted in a group of patients, waiting to attend a face-to-face physiotherapy led education and exercise group, requiring an alternative format. Therefore, the need for a virtual alternative was established. The primary aim of the project was to develop and evaluate a patient self-learning resource that may be used on an individual basis, with virtual clinician support, or as part of a virtual group. The secondary aim was to develop and implement the use of this learning resource with patients on the physiotherapy led education and exercise group waiting list in a virtual environment. The tertiary aim of this project was to determine whether this virtual alternative would be an effective means of delivering pain management education during the covid-19 pandemic and beyond. Methods: A working group developed a patient self-management workbook based on the FPMS ‘Self-Management Jigsaw’ tool. An operational procedure was developed and implemented on how the workbook could be used during the pandemic and subsequent restrictions. Patients on the pre-pandemic group waiting list were invited to participate in the programme. The patients had a choice of (1) a telephone supported programme or (2) a video group programme. Due to the limitations of the service at the time, the telephone programme commenced first. The working group implemented the telephone programme operational procedure and collected patient and staff quantitative and qualitative feedback to determine the effectiveness of the intervention. Once feedback was analysed, the group made minor changes to the workbook and developed an operational procedure for a virtual video group programme. This programme was piloted and qualitative and quantitative data was collected, analysed and compared to the telephone pilot group. Results: This project demonstrated the usefulness of a workbook to support pain education virtually. The workbook was better received in the video group (9.75/10) to the telephone cohort (7.5/10). Due to limitations within this pilot project, we are unable to ascertain the reason for this. The telephone support was equally effective and valuable in both pilot groups from both quantitative and qualitative data. Both groups reported high satisfaction rates with an average of 9.5/10, with multiple positive qualitative feedback. This data suggest the user led video approach supported engagement within the group based on the comparison of retention rates. Conclusion(s): The project demonstrates that these programmes have the potential to be an effective means of delivering pain education and have a place within the service post Covid-19. However, they are very much in their infancy and further virtual programmes within the FPMS are required to determine longer term effectiveness and efficiency. Impact: Further research is required to determine whether the delivery of virtual physiotherapy led pain education and exercise groups are effective and offer comparable results to face-to-face groups. Additionally, research is required to establish which factors enable service users to engage effectively with virtual physiotherapy led pain education and exercise programmes. Funding acknowledgements: This work was not funded.