Yoder B.A.,University of Utah |
Stoddard R.A.,Utah Valley Regional Medical Center |
Li M.,Hebei Provincial Childrens Hospital |
King J.,University of Utah |
And 2 more authors.
Pediatrics | Year: 2013
BACKGROUND AND OBJECTIVE: Heated, humidified high-flow nasal cannula (HHHFNC) is commonly used as a noninvasive mode of respiratory support in the NICU. The safety and efficacy of HHHFNC have not been compared with other modes of noninvasive support in large randomized trials. The objective was to assess the efficacy and safety of HHHFNC compared with nasal continuous positive airway pressure (nCPAP) for noninvasive respiratory support in the NICU. METHODS: Randomized, controlled, unblinded noncrossover trial in 432 infants ranging from 28 to 42 weeks' gestational age with planned nCPAP support, as either primary therapy or postextubation. The primary outcome was defined as a need for intubation within 72 hours of applied noninvasive therapy. RESULTS: There was no difference in early failure for HHHFNC (23/212 [10.8%]) versus nCPAP (18/220 [8.2%]; P =.344), subsequent need for any intubation (32/212 [15.1%] vs 25/220 [11.4%]; P =.252), or in any of several adverse outcomes analyzed, including air leak. HHHFNC infants remained on the study mode significantly longer than nCPAP infants (median: 4 vs 2 days, respectively; P <.01), but there were no differences between study groups for days on supplemental oxygen (median: 10 vs 8 days), bronchopulmonary dysplasia (20% vs 16%), or discharge from the hospital on oxygen (19% vs 18%). CONCLUSIONS: Among infants ≥28 weeks' gestational age, HHHFNC appears to have similar ef ficacy and safety to nCPAP when applied immediately postextubation or early as initial noninvasive support for respiratory dysfunction. Copyright © 2013 by the American Academy of Pediatrics.
Pearson J.K.,Utah Valley Regional Medical Center |
Tan G.M.,2 Childrens Hospital Colorado
Seminars in Cardiothoracic and Vascular Anesthesia | Year: 2015
One of the more challenging cases facing a pediatric anesthesiologist is the management of patients presenting with an anterior mediastinal mass (AMM). Patients with an AMM may have severe cardiopulmonary compromise that can be exacerbated when undergoing general anesthesia. Several case reports have documented cardiopulmonary collapse during induction or maintenance of general anesthesia and even for procedures done without anesthesia. Despite increased understanding and management of these patients, perioperative complications, defined as anything from transient decreases in blood pressure correcting with fluids or mild airway obstruction requiring no intervention, to complete cardiopulmonary collapse, are still estimated to occur during 9% to 20% of anesthetic procedures. The purpose of this review article is to provide foundational knowledge of the anatomy and physiology of a patient with an AMM, with particular emphasis on the pediatric patient. It will assist in recognizing presenting signs and symptoms and discuss the appropriate preoperative testing, which together can help assess perioperative risk and determine the appropriate anesthetic management plan for the patient's safety and comfort. © The Author(s) 2015.
Feltovich H.,Utah Valley Regional Medical Center |
Feltovich H.,University of Wisconsin - Madison |
Hall T.J.,University of Wisconsin - Madison |
Berghella V.,Thomas Jefferson University
American Journal of Obstetrics and Gynecology | Year: 2012
Spontaneous preterm birth is a heterogeneous phenotype. A multitude of pathophysiologic pathways culminate in the final common denominator of cervical softening, shortening, and dilation that leads to preterm birth. A precise description of specific microstructural changes to the cervix is imperative if we are to identify the causative upstream molecular processes and resultant biomechanical events that are associated with each unique pathway. Currently, however, we have no reliable clinical tools for quantitative and objective evaluation, which likely contributes to the reason the singleton spontaneous preterm birth rate has not changed appreciably in >100 years. Fortunately, promising techniques to evaluate tissue hydration, collagen structure, and/or tissue elasticity are emerging. These will add to the body of knowledge about the cervix and facilitate the coordination of molecular studies and ultimately lead to novel approaches to preterm birth prediction and, finally, prevention. © 2012 Mosby, Inc.
Larkin T.,Utah Valley Regional Medical Center |
Kiehn T.,Intermountain Healthcare |
Murphy P.K.,Evenflo Company |
Uhryniak J.,Evenflo Company
Advances in Neonatal Care | Year: 2013
PURPOSE: To determine whether exclusively pumping mothers of preterm infants could achieve full milk production while using the Ameda Platinum breast pump the first 14 days postpartum. SUBJECTS: Twenty-six mothers who delivered infants between 26 and 32 weeks' gestation at 2 Intermountain Healthcare hospitals completed the study. Mothers could not take milk-enhancing or milk-reducing substances, feed directly at the breast, have had breast surgery, or use any other breast pump during the study. DESIGN: Nonexperimental, descriptive study. METHODS: Mothers were instructed to use the Ameda Platinum breast pump exclusively 8 times daily, for 14 days. They recorded milk volumes, suction pressures, cycle speeds, and time spent pumping. A "Performance Questionnaire" was completed at the end of the study with questions about the ease of use, preferred speed and suction settings, and overall performance of the pump. MAIN OUTCOME MEASURE: Full milk production was defined as 700 mL/d. Speed and suction settings, as well as average pumping session length, were analyzed in relation to categories of maximum milk volumes expressed. RESULTS: The average maximum daily milk volume for all mothers was 817 mL/d. Sixteen mothers produced milk volumes more than 700 mL/d and 9 of these mothers were able to express more than 1000 mL/d. Those with daily milk production more than 700 mL/d used lower suction pressure settings to stimulate the milk ejection reflex and to empty the breast. These higher-producing mothers also chose ending speeds of 50 to 60 cycles per minute, similar to the nutritive sucking pattern of a healthy newborn. Mothers producing less than 500 mL/d used higher suction pressures, faster ending cycle speeds, and longer pumping times. Suction pressures varied widely among all of the mothers and were influenced by the mothers' nipple or breast sensitivity, which varied from mother to mother and day to day. Mothers reported liking separate controls for speed and suction and used them to achieve maximum comfort and milk volume. CONCLUSIONS: The Ameda Platinum breast pump is an effective hospital-grade pump for exclusively pumping mothers to establish full milk production by 14 days postpartum. Separate control of speed and suction allows mothers a wide range of options to achieve greater comfort and multiple milk ejections, both of which contribute to optimal milk expression. Copyright © 2013 by The National Association of Neonatal Nurses.
Sundar K.M.,University of Utah |
Sundar K.M.,Utah Valley Regional Medical Center |
Sires M.,Utah Valley Regional Medical Center
Indian Journal of Critical Care Medicine | Year: 2013
Sepsis is the commonest cause of admission to medical ICUs across the world. Mortality from sepsis continues to be high. Besides shock and multi-organ dysfunction occurring following the intense inflammatory reaction to sepsis, complications arising from sepsis-related immunoparalysis contribute to the morbidity and mortality from sepsis. This review explores the basis for sepsis related immune dysfunction and discusses its clinical implications for the treating intensivist. Recent trends indicate that a significant proportion of septic patients succumb to the complications of secondary infections and chronic critical care illness from the initial bout of sepsis. Therefore care-givers in the ICU need to be aware of the impediments posed by sepsis-related immune dysfunction that can impair recovery in patients with sepsis and contribute to sepsis-related mortality.
Christensen M.J.,Brigham Young University |
Quiner T.E.,Brigham Young University |
Nakken H.L.,Brigham Young University |
Lephart E.D.,Brigham Young University |
And 2 more authors.
Prostate | Year: 2013
BACKGROUND High dietary intake of soy or selenium (Se) is associated with decreased risk of prostate cancer. Soy constituents and various chemical forms of Se have each been shown to downregulate expression of the androgen receptor (AR) and AR-regulated genes in the prostate. We hypothesized that downregulation of AR and AR-regulated genes by the combination of these dietary components would inhibit tumorigenesis in the TRansgenic Adenocarcinoma of Mouse Prostate (TRAMP) mouse. METHODS Male mice were exposed from conception to stock diets high or low in soy, with or without a supplement of Se-methylseleno-L-cysteine (MSC) in a 2 × 2 factorial design. Mice were sacrificed at 18 weeks. Prostate histopathology, urogenital tract (UGT) weight, hepatic activity of androgen-metabolizing enzymes, and expression of AR, AR-regulated, and AR-associated FOX family genes, in the dorsolateral prostate were examined. RESULTS High soy intake decreased activity of hepatic aromatase and 5α-reductase, expression of AR, AR-regulated genes, FOXA1, UGT weight, and tumor progression, and upregulated protective FOXO3. Supplemental MSC upregulated AKR1C14, which reduces 5α-dihydrotestosterone. CONCLUSIONS Soy is an effective pleiotropic dietary agent for prevention of prostate cancer. The finding of effects of soy on FOX family gene expression in animals is novel. Combination effects of supplemental MSC may depend upon the soy content of the basal diet to which it is added. Copyright © 2013 Wiley Periodicals, Inc.
Sundar K.M.,University of Utah |
Nielsen D.,Utah Valley Regional Medical Center |
Sperry P.,Brigham Young University
Journal of Critical Care | Year: 2012
Objective: Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality. Measures to reduce the incidence of VAP have resulted in institutions reporting a zero or near-zero VAP rates. The implications of zero VAP rates are unclear. This study was done to compare outcomes between two intensive care units (ICU) with one of them reporting a zero VAP rate. Design, Setting and Patients: This study retrospectively compared VAP rates between two ICUs: Utah Valley Regional Medical Center (UVRMC) with 25 ICU beds and American Fork Hospital (AFH) with 9 ICU beds. Both facilities are under the same management and attended by a single group of intensivists. Both ICUs have similar nursing and respiratory staffing patterns. Both ICUs use the same intensive care program for reduction of VAP rates. ICU outcomes between AFH (reporting zero VAP rate) and UVRMC (VAP rate of 2.41/1000 ventilator days) were compared for the years 2007-2008. Measurements and Main Results: UVRMC VAP rates during 2007 and 2008 were 2.31/1000 ventilator days and 2.5/1000 ventilator days respectively compared to a zero VAP rate at AFH. The total days of ventilation, mean days of ventilation per patient and mean duration of ICU stay per patient was higher in the UVRMC group as compared to AFH ICU group. There was no significant difference in mean age and APACHE II score between ICU patients at UVRMC and AFH. There was no statistical difference in rates of VAP and mortality between UVRMC and AFH. Conclusions: During comparisons of VAP rate between institutions, a zero VAP rate needs to be considered in the context of overall ventilator days, mean durations of ventilator stay and ICU mortality. © 2012 Elsevier Inc.
Pak H.-N.,Yonsei University |
Oh Y.S.,Catholic University of Korea |
Lim H.E.,Korea University |
Kim Y.-H.,Korea University |
And 2 more authors.
Heart Rhythm | Year: 2011
Background Left lateral mitral isthmus (LLMI) ablation achieves a low percentage of bidirectional conduction block in atrial fibrillation (AF) ablation. Objective The purpose of this study was to investigate whether linear ablation through the lowest voltage area on the left atrial anterior wall (LAAW) can lead to better clinical outcomes compared to LLMI ablation. Methods We obtained high-density three-dimensional (3D) voltage mapping (CARTO) of the LA in 29 patients with persistent AF and determined the area of low voltage. In the multicenter prospective study, clinical outcomes of LAAW (n = 100) and LLMI ablations (n = 100) were compared in patients with persistent AF (79.4% male, 59.4 ± 10.6 years). Results (1) The low-voltage area consistently existed on LAAW and had a correlation with the LAaorta contact area (R = 0.921, P <.0001). Mean voltage of LAAW was significantly lower than that of LLMI (P <.0001). (2) The length of LAAW ablation (37.9 ± 3.4 mm vs 26.6 ± 3.2 mm, P <.0001) was longer, but achievement of bidirectional block was higher (68.0% vs 32.0%, P = .0001) than in LLMI ablation. Mean duration of LAAW and LLMI ablations was 19.3 ± 2.9 minutes and 18.2 ± 3.7 minutes, respectively (P = .086). (3) During follow-up of 23.3 ± 7.4 months, the recurrence rate of AF after LAAW ablation (26.0%) was significantly lower than that of LLMI ablation (41.0%, P = .021) after a single procedure. Conclusion The voltage map is useful for guiding linear ablation in persistent AF patients. LAAW is the most frequent low-voltage area around the mitral annulus, and linear ablation along LAAW results in a better clinical outcome with a higher rate of bidirectional conduction block compared to LLMI ablation. © 2011 Heart Rhythm Society. All rights reserved.
Minton S.,Utah Valley Regional Medical Center |
Allan M.,United Medical Systems |
Valdes W.,TeleHealth Services
Pediatric Annals | Year: 2014
Hospitals have, for centuries, maintained a central position in the health care system, providing care for critically ill patients. Despite being a cornerstone of health care delivery, we are witnessing the beginning of a major transformation in their function. There are several forces driving this transformation, including health care costs, shortage of health care professionals, volume of people with chronic diseases, consumerism, health care reform, and hospital errors. The neonatal intensive care unit (NICU) at Utah Valley Regional Medical Center in Provo, Utah, began an aggressive redesign/quality improvement effort in 1990. It became obvious that our care processes were designed for health care deliverers and not for the families. An ongoing revamp of our care delivery processes was undertaken using significant input from a parent focus meeting, parental interviews, and development of a parent-to-parent support group. As a result of this work, it became obvious we needed a new model to truly empower parents. The idea of "NICU is Home" was born. We elected to make a mind shift, not to focus on what families think, but rather on how they think. Web cams and other video apparatus have been used in a number of NICUs across the country. We decided our equipment requirements would need to include high-resolution cameras, full high-definition video recording, autofocus, audio microphones, automatic noise reduction, and automatic low-light correction. Our conferencing software needed to accommodate multiple users and have multiple-picture capabilities, low band width, and inexpensive technology. It was recognized that a single video camera feed was insufficient to adequately capture the desired amount of information. Verbal communication between parents and their babies' principal care providers is critical. Parents loved the idea of expanding the remote NICU web cam of their baby to a two-way physician-parent communication bedside monitor. Doctors at Utah Valley Regional Medical Center now have a mobile desk using a WiFi computer/camera/audio to communicate with the family in real-time or leave a recording. © Shutterstock.
Miner C.A.,Utah Valley Regional Medical Center |
Fullmer S.,Brigham Young University |
Eggett D.L.,Brigham Young University |
Christensen R.D.,Intermountain Healthcare
Journal of Maternal-Fetal and Neonatal Medicine | Year: 2013
Objective: The severity of necrotizing enterocolitis (NEC) ranges from mild to rapidly fatal. However, the factors determining the severity are not known. Our objective was to identify statistical associations with NEC severity using a large database. Method: We conducted a retrospective, multi-institutional, multiyear, study of neonates with confirmed NEC. Results: Two-hundred-twenty neonates with Bell's stage ≥ II NEC had 225 NEC episodes (157 stage II and 68 stage III). In the 3 d before NEC was diagnosed, those who went on to stage III disease were more likely to have elevations in C-reactive protein (p < 0.0001), immature to total neutrophil ratio (p = 0.0005), and mean platelet volume (p = 0.0001), and low pH (p < 0.0001) and platelet count (p < 0.0001). Regression analysis indicated higher odds that NEC would be severe if there was an antecedent RBC transfusion (p < 0.0001) or if the first feedings were not colostrum (p = 0.017). The two factors best predicting death from NEC were; (1) a low pH (p = 0.0005) and (2) lack of early colostrum (p = 0.003). Conclusions: Strategies that reduce the severity of NEC would lower costs and improve outcomes. This study suggests that testable theories to accomplish this include means of; (1) reducing transfusions and (2) assuring early colostrum feedings. © 2013 Informa UK Ltd.