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Pinto V.L.,Monroe Hospital
ASAIO Journal | Year: 2017

Neurologic complications can occur with ECMO due to several factors. Prior studies identified neonates as having unique risk factors and neuro-imaging findings post-ECMO. The aim of this study is to describe brain MRI findings of pediatric patients treated with ECMO. We conducted a retrospective study of non-neonatal pediatric patients who underwent a comprehensive brain MRI after ECMO, between January 2000 and July 2015. We identified 47 pediatric patients in the study cohort with a median age of 8 months (IQR 3-170mo) and a median ECMO run duration of 7.15 days (IQR 3.8-10.3d). Among indications for ECMO cannulation, 12(25.5%) were cardiac, 23(48.9%) were respiratory and 12(25.5%) were ECPR cannulations. There were 33(70.2%) VA cannulations of which 14(42%) were transthoracic cannulations. There were 13 patients (27.7%) with an overall incidence of stroke: 8 patients had exclusive ischemic strokes, 2 had hemorrhagic strokes and 3 with mixed types of stroke. The number of strokes in patients on VA ECMO was significantly decreased in patients undergoing transthoracic cannulation compared to peripheral cannulation (7% vs 42%, p=0.05). Further study will be used to identify risk factors for neurological injury after ECMO and to look for outcome predictors based on neuro-radiologic findings. Copyright © 2017 by the American Society for Artificial Internal Organs

Grohar P.J.,Monroe Hospital | Helman L.J.,U.S. National Cancer Institute
Pharmacology and Therapeutics | Year: 2013

The Ewing sarcoma family of tumors or Ewing sarcoma (ES) is the second most common malignant bone tumor of childhood. The prognosis for localized Ewing sarcoma has improved through the development of intense multimodal therapy over the past several decades. Unfortunately, patients with recurrent or metastatic disease continue to have a poor prognosis. Therefore, a number of complementary approaches are being developed in both the preclinical and clinical arenas to improve these outcomes. In this review, we will discuss efforts to directly target the biologic drivers of this disease and relate these efforts to the experience with several different agents both in the clinic and under development. We will review the data for compounds that have shown excellent activity in the clinic, such as the camptothecins, and summarize the biological data that supports this activity. In addition, we will review the clinical experience with IGF1 targeted agents, ET-743 and epigenetically targeted therapies, the substantial amount of literature that supports their activity in Ewing sarcoma and the challenges remaining translating these therapies to the clinic. Finally, we will highlight recent work aimed at directly targeting the EWS-FLI1 transcription factor with small molecules in Ewing tumors. © 2012 Elsevier Inc. All rights reserved.

Downing L.J.,Monroe Hospital | Caprio T.V.,Monroe Hospital | Lyness J.M.,University of Rochester
Current Psychiatry Reports | Year: 2013

The three D's of Geriatric Psychiatry - delirium, dementia, and depression - represent some of the most common and challenging diagnoses for older adults. Delirium is often difficult to diagnose and treatment is sometimes controversial with the use of antipsychotic medications, but it is common in a variety of patient care settings and remains an independent risk factor for morbidity and mortality in older adults. Dementia may affect a significant number of older adults and is associated with delirium, depression, frailty, and failure to thrive. Treatment of dementia is challenging and while medication interventions are common, environmental and problem solving therapies may have some of the greatest benefits. Finally, depression increases with age and is more likely to present with somatic complaints or insomnia and is more likely to be reported to a primary care physician than any other healthcare provider by older adults. Depression carries an increased risk for suicide in older adults and proven therapies should be initiated immediately. These three syndromes have great overlap, can exist simultaneously in the same patient, and often confer increased risk for each other. The primary care provider will undoubtedly benefit from a solid foundation in the identification, classification, and treatment of these common problems of older adulthood. © 2013 Springer Science+Business Media New York.

Pedersen C.A.,Monroe Hospital | Schneider P.J.,University of Arizona | Scheckelhoff D.J.,American Society of HealthSystem Pharmacists
American Journal of Health-System Pharmacy | Year: 2012

Purpose. Results of the 2011 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are presented. Methods. A stratified random sample of pharmacy directors at 1401 general and children's medical-surgical hospitals in the United States were surveyed by mail. Results. In this national probability sample survey, the response rate was 40.1%. Decentralization of the medication-use system continues, with 40% of hospitals using a decentralized system and 58% of hospitals planning to use a decentralized model in the future. Automated dispensing cabinets were used by 89% of hospitals, robots were used by 11%, carousels were used in 18%, and machine-readable coding was used in 34% of hospitals to verify doses before dispensing. Overall, 65% of hospitals had a United States Pharmacopeia chapter 797 compliant cleanroom for compounding sterile preparations. Medication administration records (MARs) have become increasingly computerized, with 67% of hospitals using electronic MARs. Bar-code-assisted medication administration was used in 50% of hospitals, and 68% of hospitals had smart infusion pumps. Health information is becoming more electronic, with 67% of hospitals having partially or completely implemented an electronic health record and 34% of hospitals having computerized prescriber order entry. The use of these technologies has substantially increased over the past year. The average number of full-time equivalent staff per 100 occupied beds averaged 17.5 for pharmacists and 15.0 for technicians. Directors of pharmacy reported declining vacancy rates for pharmacists. Conclusion. Pharmacists continue to improve medication use at the dispensing and administration steps of the medication-use system. The adoption of new technology is changing the philosophy of medication distribution, and health information is rapidly becoming electronic. Copyright © 2012, American Society of Health-System Pharmacists, Inc. All rights reserved.

Muglia L.J.,Vanderbilt University | Muglia L.J.,Monroe Hospital | Katz M.,March of Dimes Foundation
New England Journal of Medicine | Year: 2010

The world's preterm birth rate continues to increase. In 2006, preterm births accounted for 12.8% of live births in the United States. Only about half the cases of prematurity result from identifiable causes. This review discusses the challenge of understanding the causes of premature birth and finding ways to prevent it. Copyright © 2010 Massachusetts Medical Society.

Hall R.T.,Monroe Hospital | Domenico H.J.,Vanderbilt University | Self W.H.,Vanderbilt University | Hain P.D.,University of Texas Southwestern Medical Center
Pediatrics | Year: 2013

BACKGROUND AND OBJECTIVE: Blood culture contamination in the pediatric population remains a significant quality and safety issue because false-positive blood cultures lead to unnecessary use of resources and testing. In addition, few studies describe interventions to reduce peripheral blood culture contamination rates in this population. We hypothesized that the introduction of a standardized sterile collection process would reduce the pediatric emergency department's peripheral blood culture contamination rate and unnecessary use of resources. METHODS: A sterile blood culture collection process was designed by analyzing current practice and identifying areas in which sterile technique could be introduced. To spread the new technique, a web-based educational model was developed and disseminated. Subsequently, all nursing staff members were expected to perform peripheral blood cultures by using the modified sterile technique. RESULTS: The peripheral blood culture contamination rate was reduced from 3.9% during the baseline period to 1.6% during the intervention period (P <0001), with yearly estimated savings of ~s250 000 in hospital charges. CONCLUSIONS: Subsequent to our intervention, there was a significant reduction of the peripheral blood culture contamination rate as well as considerable cost savings to the institution. When performed in a standardized fashion by using sterile technique, blood culture collection with low contamination rates can be performed via the insertion of an intravenous catheter. Copyright © 2013 by the American Academy of Pediatrics.

Martus J.E.,Monroe Hospital
Journal of Pediatric Orthopaedics | Year: 2016

Femoral shaft fractures are common injuries in the pediatric and adolescent age groups. Rigid intramedullary nailing is an excellent treatment option for older children and adolescents, particularly for length-unstable fractures and larger patients (>49 kg). Appropriate indications, contraindications, and preoperative assessment are described. The rigid nailing surgical technique is detailed including positioning, operative steps, pearls, and pitfalls. Complications and the reported outcomes of lateral trochanteric entry nailing are reviewed from the published series. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Staebler S.,Monroe Hospital
Advances in Neonatal Care | Year: 2011

Over the past 2 decades, perinatal and neonatal health care has become less coordinated and more competitive in the United States. The impact at the state level has been the evolution of a fragmented, perinatal system with limited access and poorer outcomes. The evidence demonstrates lower mortality risk for very low-birth-weight infants born in designated tertiary centers. Regionalized systems of perinatal care are recommended to ensure that each mother and newborn achieve optimal outcomes. This article discusses the factors impacting implementation of this model at either the state or federal level as well as the incorporation of perinatal regionalization as part of the national agenda of health care reform. Copyright © 2011 by the National Association of Neonatal Nurses.

Objective: Pulse oximetry screening of asymptomatic newborns is suggested as a life-saving procedure for the timely detection of critical congenital heart disease (CHD) in asymptomatic newborns. We evaluated this screening and report cases that demonstrate problems with screening in a non-research setting.Study Design: An elective state-directed public health screening program was evaluated in Middle Tennessee; 14 564 infants were screened after 24 h of age and before discharge. The screening was performed in a non-research setting by nurses at the local hospitals. A parallel investigation of the methods and timing of diagnosis in Middle Tennessee revealed a surprisingly high incidence of antenatal diagnosis (66%).Result: Using a saturation value of 94% as the defined normal, the positive predictive value was less than 1%, with 112 infants having a false positive case and 1 having a true positive case identified (incidence 1/34 775). The one true positive case was not referred for evaluation. One false-positive case resulted in a costly referral and hospitalization. Antenatal diagnosis when combined with physical examination detected 43 of 44 infants with critical CHD during the year-long evaluation.Conclusion: Before universal screening can be implemented, a system of care must be defined to address the educational and referral issues raised by this report. © 2011 Nature America, Inc. All rights reserved.

Dodd D.A.,Monroe Hospital
Current Opinion in Pediatrics | Year: 2013

Purpose of review To review the recent publications on pediatric heart failure and pediatric transplantation. Recent findings Little progress has been made in the chronic medical management of pediatric heart failure. Basic science studies demonstrating disparate regulation of b2-adrenergic receptors and microRNA between pediatric and adult heart failure may give clues to the lack of improvement in pediatric outcomes. Pediatric ventricular assist devices have significantly improved survival of bridge-to-transplant, but currently have too many limitations for destination therapy for children. Several areas of pediatric heart transplant have had significant developments over the last few years: the role of antibodies in mediating graft dysfunction after transplantation, ABO-incompatible transplant, extending the pediatric limits on acceptable pulmonary vascular resistance, and risk prediction of pediatric transplant outcomes. Failed single-ventricle palliation is a growing indication for heart transplantation with its own unique challenges. Summary Pediatric heart transplantation can have excellent outcomes with survival beyond 20 years after transplant common, especially in the infant. However, the growing population of children and young adults being referred for heart transplantation after failed congenital heart surgery, especially after failed single-ventricle palliation, is presenting new obstacles that may start reducing the survival rates for pediatric heart transplantation. This may in part be ameliorated by earlier referral for transplant evaluation. © 2013 Wolters Kluwer Health / Lippincott Williams & Wilkins.

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