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1.
J Palliat Med ; 25(2): 227-233, 2022 02.
Article in English | MEDLINE | ID: mdl-34847737

ABSTRACT

Background: For hospitalized children admitted outside of a critical care unit, the location, mode of death, "do-not-resuscitate" order (DNR) use, and involvement of palliative care teams have not been described across high-income countries. Objective: To describe location of death, patient and terminal care plan characteristics of pediatric inpatient deaths inside and outside the pediatric intensive care unit (PICU). Design: Secondary analysis of inpatient deaths in the Evaluating Processes of Care and Outcomes of Children in Hospital (EPOCH) randomized controlled trial. Setting/Subjects: Twenty-one centers from Canada, Belgium, the United Kingdom, Ireland, Italy, the Netherlands, and New Zealand. Measurement: Descriptive statistics were used to compare patient and terminal care plan characteristics. A multivariable generalized estimating equation examined if palliative care consult during hospital admission was associated with location of death. Results: A total of 365 of 144,539 patients enrolled in EPOCH died; 219 (60%) died in PICU and 143 (40%) died on another inpatient unit. Compared with other inpatient wards, patients who died in PICU were less likely to be expected to die, have a DNR or palliative care consult. Hospital palliative care consultation was more common in older children and independently associated with a lower adjusted odds (95% confidence interval) of dying in PICU [0.59 (0.52-0.68)]. Conclusion: Most pediatric inpatient deaths occur in PICU where patients were less likely to have a DNR or palliative care consult. Palliative care consultation could be better integrated into end-of-life care for younger children and those dying in PICU.


Subject(s)
Terminal Care , Child , Humans , Intensive Care Units, Pediatric , Palliative Care , Prospective Studies , Resuscitation Orders , Retrospective Studies
2.
JAMA ; 319(10): 1002-1012, 2018 03 13.
Article in English | MEDLINE | ID: mdl-29486493

ABSTRACT

Importance: There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. Objective: To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. Design, Setting, and Participants: A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. Interventions: The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). Main Outcomes and Measures: The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. Results: Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03). Conclusions and Relevance: Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality. Trial Registration: clinicaltrials.gov Identifier: NCT01260831.


Subject(s)
Decision Support Techniques , Heart Arrest/diagnosis , Hospital Mortality , Severity of Illness Index , Child , Child Mortality , Heart Arrest/prevention & control , Hospitalization , Humans , Intensive Care Units, Pediatric , Time Factors
3.
Curr Urol ; 10(3): 113-117, 2017 Aug.
Article in English | MEDLINE | ID: mdl-28878592

ABSTRACT

Penile erection at the time of urological surgery is a rare but problematic event which can delay, complicate or even lead to the cancellation of planned surgery. Erection may occur irrespective of the type of anesthetic method employed. Several techniques for treatment of this troublesome complication have been described in the literature, all with varying levels of success and potential adverse effects. In our experience over the last 25 years, we have found that intracavernous injection of ephedrine into the penis has a 100% success rate in safely producing detumescence with minimum side effects and should therefore be considered early among the treatment options for this condition.

4.
Trials ; 16: 245, 2015 Jun 02.
Article in English | MEDLINE | ID: mdl-26033094

ABSTRACT

BACKGROUND: The prevention of near and actual cardiopulmonary arrest in hospitalized children is a patient safety imperative. Prevention is contingent upon the timely identification, referral and treatment of children who are deteriorating clinically. We designed and validated a documentation-based system of care to permit identification and referral as well as facilitate provision of timely treatment. We called it the Bedside Paediatric Early Warning System (BedsidePEWS). Here we describe the rationale for the design, intervention and outcomes of the study entitled Evaluating Processes and Outcomes of Children in Hospital (EPOCH). METHODS/DESIGN: EPOCH is a cluster-randomized trial of the BedsidePEWS. The unit of randomization is the participating hospital. Eligible hospitals have a Pediatric Intensive Care Unit (PICU), are anticipated to have organizational stability throughout the study, are not using a severity of illness score in hospital wards and are willing to be randomized. Patients are >37 weeks gestational age and <18 years and are hospitalized in inpatient ward areas during all or part of their hospital admission. Randomization is to either BedsidePEWS or control (no severity of illness score) in a 1:1 ratio within two strata (<200, ≥ 200 hospital beds). All-cause hospital mortality is the selected primary outcome. It is objective, independent of do-not-resuscitate status and can be reliably measured. The secondary outcomes include (1) clinical outcomes: clinical deterioration, severity of illness at and during ICU admission, and potentially preventable cardiac arrest; (2) processes of care outcomes: immediate calls for assistance, hospital and ICU readmission, and perceptions of healthcare professionals; and (3) resource utilization: ICU days and use of ICU therapies. DISCUSSION: Following funding by the Canadian Institutes of Health Research and local ethical approvals, site enrollment started in 2010 and was closed in February 2014. Patient enrollment is anticipated to be complete in July 2015. The results of EPOCH will strengthen the scientific basis for local, regional, provincial and national decision-making and for the recommendations of national and international bodies. If negative, the costs of hospital-wide implementation can be avoided. If positive, EPOCH will have provided a scientific justification for the major system-level changes required for implementation. TRIAL REGISTRATION: NCT01260831 ClinicalTrials.gov date: 14 December 2010.


Subject(s)
Decision Support Techniques , Heart Arrest/prevention & control , Hospitals , Process Assessment, Health Care , Adolescent , Canada , Child , Child Mortality , Child, Preschool , Early Diagnosis , Female , Health Services Research , Heart Arrest/diagnosis , Heart Arrest/etiology , Heart Arrest/mortality , Hospital Mortality , Humans , Infant , Infant Mortality , Infant, Newborn , Intensive Care Units, Pediatric , Male , Predictive Value of Tests , Referral and Consultation , Research Design , Risk Factors , Severity of Illness Index , Time Factors , Treatment Outcome
5.
J Med Case Rep ; 4: 63, 2010 Feb 22.
Article in English | MEDLINE | ID: mdl-20175891

ABSTRACT

INTRODUCTION: Renal involvement in POEMS (polyneuropathy, organomegaly, endocrinopathy, M-band, skin changes) syndrome is considered to be an under-diagnosed phenomenon with no clear treatment path. The limited literature suggests steroids to be the drug of choice, although improvements are limited and usually reverse on withdrawal of the drug. CASE PRESENTATION: A 52-year-old Caucasian woman presenting with features consistent with POEMS syndrome developed progressive renal impairment with proteinuria. Renal biopsy revealed a membranoproliferative glomerulonephritis. She was treated with relatively low dose oral mycophenolate mofetil and prednisolone which stabilised her nephropathy and neuropathy. CONCLUSION: We describe an alternative therapeutic option in patients with this serious but poorly understood condition.

7.
J Neurotrauma ; 25(6): 615-27, 2008 Jun.
Article in English | MEDLINE | ID: mdl-18578633

ABSTRACT

Traumatic brain injury (TBI) is the leading cause of death and acquired disability in the pediatric population worldwide. We hypothesized that electroencephalography (EEG) synchrony and its temporal variability, analyzed during the acute phase following TBI, would be altered from that of normal children and as such would offer insights into TBI pathophysiology. Seventeen pediatric patients with mild to severe head injury admitted to a pediatric critical care unit were recruited along with 10 age- and gender-matched controls. Patients had two electroencephalographs performed 3 days apart. Outcome was measured at 1 year post-TBI utilizing the Pediatric Cerebral Performance Category score (PCPC). Maximal synchrony between EEG channels correlated to areas of primary injury as seen on computed tomography (CT) scan. The temporal variability of phase synchronization among EEG electrodes increased as patients recovered and emerged from coma (p < 0.001). This temporal variability correlated with outcome (Pearson coefficient of 0.74) better than the worst Glasgow Coma Scale score, length of coma, or extent of injury on CT scan. This represents a novel approach in the evaluation of TBI in children.


Subject(s)
Action Potentials , Brain Injuries/physiopathology , Cerebral Cortex/injuries , Cerebral Cortex/physiopathology , Cortical Synchronization , Electroencephalography , Adolescent , Age Factors , Brain Injuries/diagnosis , Brain Mapping/methods , Cerebral Cortex/growth & development , Child , Child, Preschool , Coma/diagnosis , Coma/physiopathology , Electroencephalography/methods , Female , Glasgow Coma Scale , Humans , Infant , Male , Nerve Net/growth & development , Nerve Net/injuries , Nerve Net/physiopathology , Outcome Assessment, Health Care , Predictive Value of Tests , Reference Values , Signal Processing, Computer-Assisted , Time Factors , Tomography, X-Ray Computed
9.
J Pharm Biomed Anal ; 40(3): 631-8, 2006 Feb 24.
Article in English | MEDLINE | ID: mdl-16311001

ABSTRACT

The cleaning verification of pharmaceutical manufacturing equipment prior to further use is a cGMP requirement. Typically, relevant data are generated by HPLC with UV detection using methods individually developed and validated for each product. This work describes the use of HPLC with mass spectrometry to analyse cleaning verification samples, a novel means of utilising this analytical technology. The initial aim was to produce a single, generic method capable of quantifying a broad range of pharmaceuticals. Ultimately, however, a more effective strategy, in terms of efficiency and reliability, proved to be application of a well-defined approach to the rapid generation of compound specific methods. Results of studies to optimise the sample preparation for a basic compound in drug development (compound 1), together with experimental results for two further compounds are presented. These demonstrated that the combination of a well defined approach to chromatographic method development and mass spectrometric detection provided methodology with advantages in terms of sensitivity. Additionally, and by virtue of its potential for general applicability, the approach proposed has the potential to improve the overall efficiency with which methods for cleaning verification samples can be developed and applied.


Subject(s)
Pharmaceutical Preparations/analysis , Chromatography, High Pressure Liquid , Drug Industry/standards , Indicators and Reagents , Mass Spectrometry , Particle Size , Reproducibility of Results , Spectrophotometry, Ultraviolet
10.
J Pharm Biomed Anal ; 32(6): 1113-22, 2003 Aug 21.
Article in English | MEDLINE | ID: mdl-12907254

ABSTRACT

Assessing the short-term stability of drug development candidates in one or more formulations to be used during their preclinical evaluation is a routine, but important, task. Typically, this is based on data generated by HPLC with ultraviolet detection of the species of interest and using methodology specifically developed and validated for the purpose. This work describes a feasibility study conducted into the use of HPLC with mass spectroscopic detection for work of this type. Experimental details and the results of trials with three different drugs, each in a different vehicle, are given. It was concluded that, by using mass spectroscopic detection, a well-defined strategy could be used to generate stability data, which offered advantages in terms of specificity, speed and sensitivity over that typically used.


Subject(s)
Chromatography, High Pressure Liquid/methods , Mass Spectrometry/methods , Pharmaceutical Preparations/analysis , Sensitivity and Specificity , Spectrophotometry, Ultraviolet
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