Resident and nurse perspectives on the use of secure text messaging systems.

BACKGROUND: As hospitals shift away from pagers and towards secure text messaging systems (STMS), limited research exists on the drawbacks of such systems. Preliminary data show that introduction of STMS can lead to a dramatic increase in interruptions, which may contribute to medical errors. OBJECTIVE: This study aimed to investigate residents' and nurses' experiences with STMS at a quaternary care children's hospital. DESIGN: This was a qualitative study with focus groups. SETTING AND PARTICIPANTS: Participants were pediatric residents and nurses at Lucile Packard Children's Hospital. INTERVENTION: Focus groups were audio recorded, transcribed verbatim, and coded by 2 independent coders. Codes were discussed until consensus was reached. MAIN OUTCOME AND MEASURES: Data was analyzed through a thematic, descriptive content analysis approach. Themes were developed alongside a framework of teamwork, patient safety, and clinician well-being. RESULTS: Three resident focus groups (n = 14) and three nurse focus groups (n = 21) were held. Six themes were identified: (1) STMS can facilitate teamwork through multiple communication modalities and technological features. (2) STMS can negatively impact teamwork by decreasing face-to-face communication and frontline decision-making. (3) STMS can promote patient safety through closed-loop communication and ready access to team members. (4) STMS can negatively impact patient safety through alarm fatigue, interruptions, and miscommunication. (5) STMS can positively impact clinician well-being through satisfaction and relationship building. (6) STMS can negatively impact clinician well-being through increased stress related to communication volume. CONCLUSION: Use of STMS in the hospital setting has many advantages as well as drawbacks. With appropriate guidelines and training designed to mitigate the drawbacks, STMS have the potential to be valuable means of communication for healthcare team members.

Very-High-Dose Prednisolone Before ACTH for Treatment of Infantile Spasms: Evaluation of a Standardized Protocol.

BACKGROUND: There is ongoing debate regarding the comparative effectiveness of adrenocorticotropic hormone and prednisolone in the treatment of infantile spasms. With a large cohort and extended follow-up, we set out to evaluate a protocol in which adrenocorticotropic hormone is reserved for prednisolone nonresponders. METHODS: The following standardized hormonal therapy protocol was adopted. Patients initially receive prednisolone (8 mg/kg/day [maximum 60 mg/day], divided in three daily doses for 14 days). Prednisolone responders taper it over 14 days, whereas prednisolone nonresponders immediately transition to natural adrenocorticotropic hormone (150 U/m2/day, divided in two daily doses for 14 days). We evaluated short-term response, defined as video-electroenecphaloagraphy-confirmed resolution of both epileptic spasms and hypsarrhythmia on day 14, without relapse for 28 additional days. We then evaluated long-term relapse and calculated the rates of sustained response at six, 12, and 18 months. RESULTS: We identified 102 children with infantile spasms who were treated with prednisolone. Prior exposure to hormonal therapy and vigabatrin was observed among 12% and 35% of patients, respectively. Sixty (59%) patients responded to prednisolone, and 13 (33%) prednisolone nonresponders then responded to adrenocorticotropic hormone. Cumulative response to prednisolone and adrenocorticotropic hormone (if needed) was higher among treatment-naive patients (84%) than among patients with prior exposure to first-line treatment (51%), with P < 0.001. Relapse was relatively common among all subgroups. CONCLUSION: Short-term response to prednisolone was favorable and higher among treatment-naive patients. These data suggest that prednisolone is a reasonable approach to initial therapy and that adrenocorticotropic hormone exhibits substantial efficacy after prednisolone failure.

Prevention of infantile spasms relapse: Zonisamide and topiramate provide no benefit.

OBJECTIVE: There is scant evidence to guide the management of infantile spasms after successful response to initial therapies. There is significant risk of relapse, largely because effective pharmacologic treatments cannot be continued long term because of concern for significant adverse events. Zonisamide (ZNS) and topiramate (TPM) are commonly used to prevent relapse, and the purpose of this study was to specifically evaluate the efficacy of ZNS and TPM as agents for secondary prevention of infantile spasms. METHODS: Patients with video-electroencephalography (EEG) confirmed resolution of infantile spasms were retrospectively identified. Relevant clinical data were systematically collected, including lead time from onset of spasms to successful treatment response, etiology of infantile spasms, number of treatment failures prior to response, timing of relapse, and detailed exposure data for ZNS and TPM. RESULTS: We identified 106 patients with response to hormonal therapy (n = 58), vigabatrin (n = 25), or surgery (n = 23). To prevent relapse of infantile spasms, 37 patients received ZNS, 34 received TPM, 3 received both ZNS and TPM, and 38 patients received neither ZNS nor TPM. There were 44 relapses, occurring a median of 6.9 (3.2-10.8) months after initial response. Time to relapse was not affected by treatment with ZNS or TPM. Relapse was less likely among patients who were older (hazard ratio 0.97 [per month], p = 0.036) and those who responded to surgical resection (hazard ratio = 0.28, p = 0.017). Of note, we identified a relatively refractory cohort with multiple treatment failures and long lead time to initial response. SIGNIFICANCE: In this refractory cohort, neither ZNS nor TPM was successful in preventing relapse of infantile spasms, despite relatively high dosages. At this time, aside from surgical resection in eligible candidates, there is no known treatment that is efficacious in the prevention of relapse of infantile spasms.