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Palma J.P.,Stanford University | Sharek P.J.,Stanford University | Longhurst C.A.,Lucile Packard Childrens Hospital | Longhurst C.A.,Stanford University
Journal of Perinatology

Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU). Study Design:Prospective surveys of neonatal care providers in an academic children's hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool. Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P0.01) and 98% were satisfied with the printed sign-out document (P0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and 25% after EMR integration of the handoff tool (P0.01). Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow. © 2011 Nature America, Inc. All rights reserved. Source

Wong C.J.,Lucile Packard Childrens Hospital | Moxey-Mims M.,U.S. National Institute of Diabetes and Digestive and Kidney Diseases | Warady B.A.,University of Missouri - Kansas City | Furth S.L.,Childrens Hospital of Philadelphia
American Journal of Kidney Diseases

Chronic kidney disease (CKD) is a life-long condition associated with substantial morbidity and premature death due to complications from a progressive decrease in kidney function. The incidence and prevalence of all stages of CKD in children continues to increase worldwide. Between 2000 and 2008, the kidney replacement therapy incidence rate in those aged 0-19 years increased 5.9% to 15 per million population, highlighting the importance of CKD research in children. Many comorbid conditions seen in adults with CKD, including cardiovascular disease and cognitive impairment, also are highly prevalent in children, implicitly demonstrating the crucial need for initiating therapy early to improve health outcomes in children with CKD. The CKiD (Chronic Kidney Disease in Children) Study is a prospective cohort study of 586 children aged 1-16 years with an estimated glomerular filtration rate of 30-90 mL/min/1.73 m2. Since its inception, CKiD has identified risk factors for CKD progression and cardiovascular disease in children with CKD and highlighted the effects of CKD on outcomes unique to children, including neurocognitive development and growth. This review summarizes the findings to date, illustrating the spectrum of CKD-associated complications in children and emphasizing areas requiring further investigation. Taken in sum, these elements stress that initiating treatment at an early age is essential for reducing long-term morbidity and mortality in children with CKD. © 2012 National Kidney Foundation, Inc. Source

Zlotnick C.,Center for the Vulnerable Child | Tam T.W.,Center for the Vulnerable Child | Soman L.A.,Lucile Packard Childrens Hospital
American Journal of Public Health

Objective: We compared the prevalence rates of mental health and physical health problems between adults with histories of childhood foster care and those without. Methods: We used 2003-2005 California Health Interview Survey data (n=70456) to test our hypothesis that adults with childhood histories of foster care will report higher rates of mental and physical health concerns, including those that affect the ability to work, than will those without. Results: Adults with a history of childhood foster care had more than twice the odds of receiving Social Security Disability Insurance because they were unable to work owing to mental or physical health problems for the past year, even after stratifying by age and adjusting for demographic and socioeconomic characteristics. Conclusions: Childhood foster care may be a sentinel event, signaling the increased risk of adulthood mental and physical health problems. A mental and physical health care delivery program that includes screening and treatment and ensures follow-up for children and youths who have had contact with the foster care system may decrease these individuals' disproportionately high prevalence of poor outcomes throughout their adulthood. Source

Getgood A.,The London Clinic | Gelber J.,University of California at Los Angeles | Gortz S.,University of California at San Diego | De Young A.,Lucile Packard Childrens Hospital | Bugbee W.,Scripps Research Institute
Knee Surgery, Sports Traumatology, Arthroscopy

Introduction: The efficacy of meniscal allograft transplantation (MAT) and osteochondral allografting (OCA) as individual treatment modalities for select applications is well established. MAT and OCA are considered symbiotic procedures due to a complementary spectrum of indications and reciprocal contraindications. However, few outcomes of concomitant MAT and OCA have been reported. This study is a retrospective review of patients who received simultaneous MAT and OCA between 1983 and 2011. Methods: Forty-eight (twenty-nine male: nineteen female) patients with a median age of 35.8 years (15–66) received combined MAT and OCA procedures between 1983 and 2011. Forty-three patients had received previous surgery with a median of 3 procedures (1–11 procedures). The underlying diagnosis was trauma (tibial plateau fracture) in 33 % with osteoarthritis predominating in 54.2 % of cases. Thirty-one patients received a lateral meniscus, 16 received a medial meniscus and one patient received bilateral MAT. The median number of OCAs was two per patient (1–5 grafts), with a median graft area of 15 cm2 (0.7–41 cm2). There were 21 unipolar, 24 bipolar (tibiofemoral) and three multifocal lesions. Thirty-six MATs constituted a compound tibial plateau OCA with native meniscus attached. At follow-up, failure was defined as any procedure resulting in removal or revision of one or more of the grafts. Patients completed the modified Merle d’Aubigné and Postel (18-point) scale, Knee Society Function (KS-F) score, and subjective International Knee Documentation Committee (IKDC) scores. Patient satisfaction was also captured. Results: Twenty-six of 48 patients (54.2 %) required reoperation, but only 11 patients (22.9 %) were noted to have failed (10 MAT and 11 OCA). The mean time to failure was 3.2 years (95 % CI 1.5–4.9 years) and 2.7 years (95 % CI 1.3–4.2 years) for MAT and OCA, respectively. The 5-year survivorship was 78 and 73 % for MAT and OCA respectively, and 69 and 68 % at 10 years. Six of the failures were in the OA cases and one was an OCD lesion where bipolar grafts were utilized. The OCD case underwent a revision OCA and remains intact. The others were converted to knee arthroplasty. One case failed due to early deep infection, ultimately requiring arthrodesis. Of those with grafts still intact, the mean clinical follow-up was 6.8 years (1.7–17.1 years). Statistically significant improvements in all outcome scores were noted between baseline and the latest follow-up. In total, 90 % of those responding would have the surgery again and 78 % were either extremely satisfied or satisfied with the outcome. Conclusion: The overall success rate of concomitant MAT and OCA was comparable with reported results for either procedure in isolation. A trend towards  a worse outcome was observed with bipolar tibiofemoral grafts in the setting of OA. Comparatively better results in less advanced, unipolar disease could suggest a benefit to early intervention that might merit a lower treatment threshold for combined MAT and OCA. Level of evidence: IV. © 2015, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA). Source

Enns G.M.,Lucile Packard Childrens Hospital
Molecular Genetics and Metabolism

Although the protocol that most experienced metabolic centers in the United States follow for treating acute hyperammonemia in urea cycle disorders (UCDs) is similar to that proposed by Brusilow and Batshaw in the early 1980s, over the years a steady evolution has taken place. Continued developments in intensive care, surgical and hemodialysis techniques, fluid and electrolyte management, cardiovascular support, and emergency transport have contributed to improved management of acute hyperammonemia. Compared to historical data, survival of urea cycle patients has also improved following treatment with alternative pathway therapy, in addition to appropriate supportive care, including the provision of adequate calories to prevent catabolism and promote anabolism and hemodialysis if needed. However, overall neurological outcomes have been suboptimal. There are currently a number of exciting prospective new therapies on the horizon, including novel medications or cell-based treatments. Nevertheless, the therapeutic expertise that is currently in place at centers specializing in management of metabolic emergencies already has the potential to improve survival and outcome in these children significantly. The early identification of UCD patients so that transport to a metabolic treatment center may be carried out without delay continues to be a major area of focus and challenge. © 2010 Elsevier Inc. All rights reserved. Source

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