Blood conservation pediatric cardiac surgery in all ages and complexity levels.

AIM: To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery. METHODS: We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) from 2010-2015. The patients were grouped into blood conservation (n = 138) and non-conservation (n = 218) groups and sub-grouped based on their ages and procedural complexity scores. RESULTS: There were no statistical differences in gender, weight, pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups, there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels. CONCLUSION: Blood conservation surgery can be performed in congenital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.

National trends and variability in blood utilization in paediatric cardiac surgery.

OBJECTIVES: Red blood cell transfusion is a common practice in paediatric cardiac surgery. Transfusion of red blood cells has been shown to be associated with an increase in morbidity in paediatric patients undergoing cardiac surgery. There is a huge variability in the practice of blood utilization within and across different practices. The aim of this study was to demonstrate the current variability and the trends over the past decade in blood usage among children's hospitals performing paediatric cardiac surgery. METHODS: We performed a retrospective observational cohort study using the Paediatric Health Information System database from 43 participating paediatric hospitals in the USA. All discharge billing information for patients younger than 19 years of age who underwent cardiac surgery using cardiopulmonary bypass between 2005 and 2015 was investigated. Ten index diagnoses and procedures were investigated and analysed, based on age differences and on the Society of Thoracic Surgeon & European Association for Cardio-Thoracic Surgery mortality scores. Our main outcome variable was the unit(s) of homologous red blood cells charged for the first 24 h of admission for cardiac surgery. RESULTS: There was significant variability in red blood cell usage for a given diagnosis and procedural code across all the centres despite varied age ranges and complexity scores for the current and the last decade of paediatric cardiac surgical patients. CONCLUSIONS: We found a discernible variability in the current practice of blood utilization for a given procedure despite variability in the age and complexity of patients, with no changes in practice patterns for the last decade of paediatric cardiac surgery.

Treatment of blastic plasmacytoid dendritic cell neoplasm.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare myeloid malignancy with no defined standard of care. BPDCN presents most commonly with skin lesions with or without extramedullary organ involvement before leukemic dissemination. As a result of its clinical ambiguity, differentiating BPDCN from benign skin lesions or those of acute myeloid leukemia with leukemia cutis is challenging. BPDCN is most easily defined by the phenotype CD4+CD56+CD123+lineage-MPO-, although many patients will present with variable expression of CD4, CD56, or alternate plasmacytoid markers, which compounds the difficulty in differentiating BPDCN from other myeloid or lymphoid malignancies. Chromosomal aberrations are frequent, and the mutational landscape of BPDCN is being rapidly characterized although no obvious molecular target for chemoimmunotherapy has been identified. Chemotherapy regimens developed for acute myeloid leukemia, acute lymphoid leukemia, and myelodysplastic syndrome have all been used to treat BPDCN. Relapse is frequent, and overall survival is quite poor. Allogeneic transplantation offers a chance at prolonged remission and possible cure for those who are eligible; unfortunately, relapse remains high ranging from 30% to 40%. Novel therapies such as SL-401, a diphtheria toxin conjugated to interleukin-3 (IL-3) is commonly overexpressed in BPDCN and other aggressive myeloid malignancies and has shown considerable promise in ongoing clinical trials. Future work with SL-401 will define its place in treating relapsed or refractory disease as well as its role as a first-line therapy or bridge to transplantation.

Persistent Pulmonary Hypertension in a Neonate With Transposition of Great Arteries and Intact Ventricular Septum: A Case Report and Review of the Literature.

Transposition of the great arteries (TGA) with intact ventricular septum (IVS) has very favorable short- and long-term surgical outcome. Although rare, when associated with persistent pulmonary hypertension (PPH), it exhibits significant mortality risk and management challenges. We report the case of a neonate with TGA with IVS and PPH who underwent successful early surgical repair with emphasis on clinical management and review of the literature.

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

BACKGROUND: Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates. OBJECTIVE: The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital. PATIENTS AND METHODS: We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation. RESULTS: After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame. CONCLUSION: Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.

Shame and guilt in preschool depression: evidence for elevations in self-conscious emotions in depression as early as age 3.

BACKGROUND: Empirical findings from two divergent bodies of literature illustrate that depression can arise in the preschool period and that the complex self-conscious emotions of guilt and shame may develop normatively as early as age 3. Despite these related findings, few studies have examined whether the emotions of shame and guilt are salient in early childhood depression. This is important to further understand the emotional characteristics of preschool depression. Based on the hypothesis that preschool depression would be uniquely associated with higher levels of shame and maladaptive guilt, these emotions were investigated in a sample that included depressed, anxious, and disruptive disordered preschoolers as well as healthy peers using multiple methods. METHOD: Structured psychiatric diagnoses were derived in a sample of N = 305 preschoolers ascertained from community sites. Preschoolers' tendency to experience shame and guilt were explored using a story stem completion task coded by raters blind to symptoms and diagnosis of the subjects. Guilt experience and reparation behaviors were also measured using parent report. RESULTS: Based on preschooler's emotion themes during the narrative tasks, gender, age, and depression severity predicted unique and significant portions of the variance in preschoolers' expressions of shame. Parent report measures revealed that increasing depression severity was associated with children's more frequent experiences of guilt feelings and less frequent attempts at guilt reparation (maladaptive guilt). CONCLUSIONS: Findings demonstrated that high levels of shame and maladaptive guilt were related to preschool onset depression when using observational measures of children's internal representations of their self-conscious emotions as well as parent report. These findings demonstrate continuity of these core emotions of depression as early as age 3. These findings suggest that guilt and shame should be explored in clinical assessments of young children and may be an important focus for future studies of the developmental psychopathology of depression.

Gender differences in emotional reactivity of depressed and at-risk preschoolers: implications for gender specific manifestations of preschool depression.

We investigated whether differences in positive and negative emotional reactivity could be found in depressed preschoolers and preschoolers at risk for later internalizing symptoms relative to nondepressed/low risk comparison groups. Observational measures of emotional reactivity, used to derive a score of the balance between anger and sadness, were obtained and analyzed in independent samples. One study utilized cross-sectional data from preschoolers (M age = 4.6 years) with a current depressive syndrome and two nondepressed comparison groups. The other study utilized longitudinal data that assessed emotional reactivity at preschool age (M age = 4.5 years) and later mental health symptoms during the transition to primary school, allowing a retrospective determination of risk. Depressed and at-risk boys displayed more anger than sadness in contrast to girls in the same groups and in contrast to no disorder/low-risk controls. This finding was detected in depressed and "at risk for internalizing" boys who were not comorbid for externalizing problems.

Depressed and healthy preschoolers' internal representations of their mothers' caregiving: associations with observed caregiving behaviors one year later.

This study examined diagnostic group differences in children's internal representations of their mothers and mothers' parenting strategies 1 year later. Mother - preschool child dyads (N = 279) were examined. The sample included 151 healthy, 75 depressed, and 53 disruptive disordered preschoolers. The MacArthur Story Stem Battery (MSSB) was administered at baseline. One year later, mothers' caregiving strategies were measured. Results indicated that higher depression severity was associated with preschoolers' greater use of negative and disciplinarian maternal representations. More positive maternal representations had supportive mothers who often expressed positive affect 1 year later. Preschoolers' negative and disciplinarian representations were associated with mothers' later nonsupportive behaviors and negative affect. Results suggest that the MSSB may be a useful child-informant method for interpreting depressed children's internalization of caregiving relationships.

Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital.

CONTEXT: Introduction of a rapid response team (RRT) has been shown to decrease mortality and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients. No published studies to date show significant reductions in mortality or cardiopulmonary arrests in pediatric inpatients. OBJECTIVE: To determine the effect on hospital-wide mortality rates and code rates outside of the ICU setting after RRT implementation at an academic children's hospital. DESIGN, SETTING, AND PARTICIPANTS: A cohort study design with historical controls at a 264-bed, free-standing, quaternary care academic children's hospital. Pediatric inpatients who spent at least 1 day on a medical or surgical ward between January 1, 2001, and March 31, 2007, were included. A total of 22,037 patient admissions and 102,537 patient-days were evaluated preintervention (before September 1, 2005), and 7257 patient admissions and 34,420 patient-days were evaluated postintervention (on or after September 1, 2005). INTERVENTION: The RRT included a pediatric ICU-trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. This team was activated using standard criteria and was available at all times to assess, treat, and triage decompensating pediatric inpatients. MAIN OUTCOME MEASURES: Hospital-wide mortality rates and code (respiratory and cardiopulmonary arrests) rates outside of the ICU setting. All outcomes were adjusted for case mix index values. RESULTS: After RRT implementation, the mean monthly mortality rate decreased by 18% (1.01 to 0.83 deaths per 100 discharges; 95% confidence interval [CI], 5%-30%; P = .007), the mean monthly code rate per 1000 admissions decreased by 71.7% (2.45 to 0.69 codes per 1000 admissions), and the mean monthly code rate per 1000 patient-days decreased by 71.2% (0.52 to 0.15 codes per 1000 patient-days). The estimated code rate per 1000 admissions for the postintervention group was 0.29 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.65; P = .008), and the estimated code rate per 1000 patient-days for the postintervention group was 0.28 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.64; P = .007). CONCLUSION: Implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rate and code rate outside of the pediatric ICU setting.

Preschoolers' contribution to their diagnosis of depression and anxiety: uses and limitations of young child self-report of symptoms.

BACKGROUND: The assessment of psychopathology in preschool aged children has traditionally relied exclusively on adult informants as children under 6 years-of-age have been widely regarded as developmentally unable to serve as valid reporters of their own mental state. Based on the finding of a valid preschool depressive syndrome, methods to obtain self-report of symptoms of depression and related anxiety directly from the child are now needed. METHODS: The Berkeley Puppet Interview (BPI), a novel measure of psychopathology designed for the young child informant, was administered to N = 110 preschool study subjects aged 4.0-5.6 who participated in a comprehensive assessment of preschool depression. Parents filled out the Child Behavioral Checklists (CBCL) and the diagnosis was derived using parent report on the Diagnostic Interview Schedule for children, version IV (DISC-IV-YC) at baseline and 6 months later. RESULTS: Findings suggest that young children may serve as useful reporters of several core and basic symptoms of depression and anxiety based on significant correlations with a variety of parent report measures administered concurrently and 6 months later. However, no significant correlations were found between preschool reports of more complex or abstract symptoms. CONCLUSION: These findings taken together suggest that the young child can validly self-report on some key aspects of depression and anxiety and that self-report of young children should be sought in these domains. Findings also suggested that these self-reports are limited to the core and basic symptoms of these disorders and that direct age appropriate approaches may not be useful beyond that domain.

Music for the injured soldier: a contribution of American women's military bands during World War II.

This study is an investigation of the contributions of women's military bands in the United States to the reconditioning of the injured American troops during World War II. Primary and secondary sources revealed that these bands welcomed home hospital ships, performed for convalescing soldiers in hospitals, and provided music for hospital dances. While each of the bands investigated served in similar capacities, only one, the 403rd Women's Army Corps (WAC) Band, was stationed at a hospital. While entertainment by women's bands was an important part of the Army Reconditioning Program for the injured, the study also revealed a working partnership that developed between these musicians and the medical community. Sixty years after the war, band members believe their performances in hospitals were the most important contribution of their service. Some historians have concluded that music used in military hospitals during the war was the impetus for the music therapy profession.

An observational analysis of behavior in depressed preschoolers: further validation of early-onset depression.

OBJECTIVE: To investigate whether higher levels of negative and lower levels of positive behaviors could be observed in a sample of depressed preschoolers. Support for the validity of preschool depression is now available; however, objective evidence of negative behaviors among depressed preschoolers is needed. METHOD: A structured observational parent-child interaction task was conducted. The behaviors of 152 preschoolers (ages 3.0-5.6) in three study groups (depressed, disruptive, and healthy) were examined with further analyses of depressed subgroups based on severity and comorbidity. RESULTS: Anhedonically depressed preschoolers emerged as demonstrating less enthusiasm, more avoidance, more noncompliance, and having a more negative overall experience than healthy controls. This more severe and proposed melancholic anhedonic subgroup also displayed less enthusiasm than nonanhedonically depressed preschoolers. Furthermore, the "pure" anhedonic depressed preschoolers without disruptive comorbidity emerged as the only depressed subgroup that was significantly distinguishable from healthy preschoolers. CONCLUSIONS: Findings provide the first objective evidence of more negative and fewer positive behaviors among depressed preschoolers. Notably, the finding that anhedonically depressed preschoolers demonstrated significantly less enthusiasm than those with nonanhedonic depression provides the first objective evidence of the manifestation of anhedonia, a key sign of preschool depression. The implications of the finding that the "pure" anhedonic depressed subgroup without disruptive comorbidity was most distinguishable from comparison groups are explored.