Inpatient child neurology programs provide essential services for children. We sought to understand the current structure and challenges of inpatient pediatric neurologic care delivery in academic ...programs in North America.
We identified a single child neurologist from 39 of the first 40 programs on the 2019-2020 US News and World Report ranking and 3 large Canadian programs to be invited to participate in an inpatient focused survey. In October 2020, these 42 child neurologists were invited to complete an anonymous on-line survey including 37 questions about the structure, workload, and challenges of their inpatient program. Data were analyzed descriptively.
We received responses from 30/42 (71%) invited child neurologists from unique programs. Most (22/30, 73%) were Child Neurology Program Directors, Inpatient Directors, and/or Division Chiefs. Two-thirds (20/30, 67%) reported a total of 2-4 inpatient services. Two-thirds (20/30, 67%) reported a primary neurology admitting service. Nearly two-thirds (19/30, 63%) reported a separate intensive care unit service, and approximately one-third (11/30, 37%) reported a separate stroke/vascular service. Half of the respondents (15/30, 50%) reported some attendings whose primary clinical effort is in the inpatient setting. Over half (17/30, 57%) reported having trainees interested in inpatient-focused careers. Approximately half (16/30, 53%) reported a full-time equivalent metric for inpatient time, and under half (13/30, 43%) reported the use of critical-care billing. Most respondents (26/30, 87%) endorsed that inpatient attendings frequently complete documentation/sign notes outside of normal daytime hours. During night call, attendings commonly spend 30 minutes-2 hours on patient care-related phone calls between 5 and 10 pm (24/30, 80%) and receive 1-3 patient care-related phone calls after 10 pm (21/30, 70%). Faculty burnout was the biggest inpatient-specific challenge before the coronavirus disease 2019 (COVID-19) pandemic (25/30, 83%), and concern about faculty well-being during the COVID-19 pandemic was reported in nearly all respondents (28/30, 93%).
Academic child neurology programs in North America implement varied models for inpatient care delivery and face common challenges. The information presented in this study serves to stimulate discussion, help optimize operations, and encourage novel approaches to accomplish work and advance careers in academic inpatient child neurology.
Hemorrhagic transformation can complicate both arterial ischemic stroke and cerebral sinus venous thrombosis. Risk factors for hemorrhagic transformation after adult arterial ischemic stroke include ...larger infarct volume, cardioembolic stroke, and anticoagulation in the acute period. Large hemorrhagic transformation in adults is associated with poor outcome. Therefore hemorrhagic transformation is used as a safety end point for most arterial ischemic stroke acute treatment and secondary prevention trials. Up to 30% of children with arterial ischemic stroke have hemorrhagic transformation, most of which are petechial. As in adults, large infarct size is the greatest predictor of hemorrhagic transformation, but in children, acute anticoagulation is not a clear predictor of hemorrhage. As use of acute endovascular interventions for arterial ischemic stroke has expanded in adults, these therapies have also been used in some teenagers and even younger children. More information, including safety data with end points like hemorrhagic transformation, is needed in the pediatric population. In adults with cerebral sinus venous thrombosis, including those with hemorrhagic transformation, acute anticoagulation is associated with better outcomes and is the standard of care. Some hemorrhagic transformation may be evident at baseline in over half of children and neonates with cerebral sinus venous thrombosis. Anticoagulation-associated hemorrhage in pediatric cerebral sinus venous thrombosis occurs in about 10% of children but is not clearly related to outcome, whereas lack of anticoagulation may be associated with clot propagation and worse outcomes. This review provides background on hemorrhagic transformation of ischemic stroke in adults and summarizes literature regarding hemorrhagic transformation of pediatric arterial ischemic stroke and cerebral sinus venous thrombosis, with a focus on implications for acute treatment and outcome.
Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, ...occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.
Antibody-mediated encephalitis is a treatable cause of encephalitis that manifests over days to weeks as changes in behavior and cognition, seizures, movement disorders, and autonomic dysfunction. ...Patients with autoimmune encephalitis develop a variety of symptoms. As such, they require a multidisciplinary approach to care. In this review we summarize the clinical presentation and practical diagnostic approach to pediatric autoimmune encephalitis, review treatments of the autoimmune process, and discuss the management of the acute symptoms encountered in children.
To describe factors affecting eligibility for, and rates of utilization of, hyperacute therapy in children with acute ischemic stroke (AIS) following establishment of our institutional acute stroke ...treatment pathway in 2005.
A retrospective analysis of a prospectively enrolled, single-center cohort was performed including children age 2 – <18 years with acute AIS from 2005 through 2017. Descriptive statistics were used to summarize clinical characteristics, presentation data, and Pediatric NIH Stroke Scale (PedNIHSS) scores that were abstracted from medical records. Assessment for eligibility and administration of hyperacute therapy was determined at the time of presentation according to the institutional stroke pathway.
Of 90 children (median age at presentation 11.3 years, 36% female) with acute AIS, 5 (6%) received hyperacute therapy: 3 received intravenous tissue plasminogen activator (IV-tPA) alone, 1 received endovascular therapy (EVT) alone, and 1 received IV-tPA and EVT. Of 54 children (60%) who presented within 4.5 h of time last seen well, 6 had PedNIHSS scores 6–24, no medical contraindication to IV-tPA, and a partial or complete vessel occlusion. Of 7 children >3 years old who presented after EVT became available at our hospital and within 6 h of time last seen well with a PedNIHSS score 6–24, 3 (43%) had a large vessel occlusion (LVO). Two patients underwent EVT and the other patient was not transferred until >6 h from time last seen well.
Delay to presentation and diagnosis of childhood acute AIS, mild neurologic deficits at presentation, medical contraindications to IV-tPA, and lack of vessel occlusion on acute neuroimaging contribute to low rates of hyperacute treatment in children with acute AIS.
•There are low rates of acute reperfusion intervention for childhood ischemic stroke.•Children often present outside the current guideline time window for intervention.•Mild neurologic deficit or lack of vessel occlusion limits intervention eligibility.•Medical contraindications for intravenous tissue plasminogen activator are common.
•Equine mortality composting is effective during spring and fall in Minnesota.•Mostly large bones remained in compost piles after 6 months of composting.•Composting reduced estimated sodium ...pentobarbital quantities.•Physicochemical characteristics of compost were suitable for land application.
Recent changes in rendering availability for chemically-euthanized animals have created a need to explore composting as an equine mortality management method. The objectives of this study were to evaluate equine mortality composting in the Upper Midwest during fall and spring, document sodium pentobarbital concentrations throughout the process, and determine nutrient content of finished compost. During each season, four horses were euthanized by intravenous administration of sodium pentobarbital. Carcasses were positioned at the center of a woodchip and shavings base and covered with a 2:1 mixture of horse stall waste and cattle feedlot waste. Data loggers were placed at 46- and 91cm depths to record pile temperatures every 8 hours. At turning (44–50 days) and trial conclusion (181–216 days), compost piles were sampled for sodium pentobarbital and nutrient composition. Piles contained large bones after 6 months of composting. Sodium pentobarbital remained detectable at trial conclusion (<0.002–1.49 mg kg1 dry matter); however, composting reduced the estimated quantities of sodium pentobarbital by ≥94% (P ≤ .001). Compost from each season met ideal land application values for organic matter (45%–48%), pH (7.3–7.6), and electrical conductivity (3.3–3.4 mm hos cm−1). Low NPK and high C:N ratio (20–30) indicate compost could partially replace synthetic fertilizers when land applied. These findings suggest equine mortality composting is an effective management practice during fall and spring in the Upper Midwest. While remaining sodium pentobarbital residues were minimal, further research is needed to determine environmental implications of composting chemically-euthanized equines.
•Surveys were used to assess end-of-life decisions made by owners and veterinarians.•Most respondents were middle aged women with long-term industry involvement.•Respondents preferred chemical ...euthanasia and burial over other methods.•Limited research and knowledge remain barriers to wide acceptance of composting.•Most respondents would be willing to try composting if more research was available.
Challenges associated with burial, rendering, and cremation have forced horse owners to seek alternative mortality disposal methods. While equine mortality composting has been successfully demonstrated, industry-wide adoption has been limited. Therefore, evaluation of horse owners’ and veterinarians’ perceptions and experience with mortality composting is needed. Two surveys were developed to evaluate industry practices and decisive factors regarding equine euthanasia and mortality disposal methods. Each survey was designed for a separate audience: horse owners or veterinarians serving equines. The surveys were advertised as weblinks on relevant Facebook pages, e-newsletters, and email listservs. Data were analyzed using bivariate and multivariate models for associations and factors influencing decisions surrounding composting. The surveys yielded 1,225 and 244 usable responses from horse owners and veterinarians, respectively. Respondent demographics were consistent with previous survey reports for horse owners and veterinarians in the United States with a majority being female between 41 and 60 years of age with long-term industry involvement. Horse owners (86%) and veterinarians (84%) that preferred chemical euthanasia tended to prefer burial (58% and 42%, respectively) over other mortality disposal methods. Only 12% of horse owner respondents had ever tried composting and only 25% of veterinarian respondents had ever recommended composting. Horse owner (47%) and veterinarian (67%) respondents indicated they would be more open to trying and recommending mortality composting if more scientific research were available. Equine mortality composting shows potential as a primary disposal method for the equine industry. Research and educational programs are key to industry-wide acceptance of equine mortality composting.
Objective
To describe changes in hospital-based care for children with neurologic diagnoses during the initial 6 weeks following regional Coronavirus 2019 Shelter-in-Place orders.
Methods
This ...retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6 weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3 years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record.
Results
27,900 encounters over 4 years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5 years vs 7 years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all P<.01)).
Conclusion
During the initial 6 weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.
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