Since humans are an integral part of healthcare delivery, it is appropriate to understand how human nature and human error impact patient safety. A thorough understanding of the interactions between ...humans and the medical environment could help decrease errors that result in patient harm. This article describes some of our findings from a study that revealed unexpected behaviors which were documented on video during critical events (cardiac arrests) in a pediatric cardiac intensive care unit (CICU). We changed our training process for cardiac arrests as well as our nurse staffing in the CICU based upon results of our study. We believe that the lessons learned in our CICU are generalizable to both inpatient and ambulatory settings. We also emphasize the importance of collaborating with social scientists to rigorously study innate maladaptive patterns of human behavior to determine strategies to mitigate “human factors” during acute medical crises.
How does an intellectual property (IP) legal regime affect those who make their living on counterfeit commodities, and in return how do these people respond to the implementation of IP laws? In this ...ethnographic study, I analyze the effects of an IP legal regime in two Chinese markets, and use legal consciousness theories and methods to show how this legal regime results in greater social inequality. While the majority of business owners in my study engage in counterfeiting, their tactics in response to the enforcement of IP laws vary significantly. Small shopkeepers at one market, the primary target of enforcement, adopt the legal consciousness of resistance. Established trademark and logo owners at the other market adopt tactics of evasion to maintain the appearance of lawful practices. I argue that these two types of tactics embody different forms of legal consciousness. The divergent tactical responses strengthen the second group of business owners who have greater power and resources at the expense of the first group who have less, thus aggravating their socioeconomic disparities.
Objective
To describe the clinical characteristics, perioperative complications, and outcomes in dogs surgically treated for gastric carcinoma.
Study design
Multi‐institutional retrospective case ...series.
Animals
Forty client‐owned dogs with histologically confirmed gastric carcinoma.
Methods
Medical records were reviewed for preoperative diagnostics, surgery, histopathology, postoperative complications, adjuvant chemotherapy, disease progression, and survival. Variables were assessed for associations with outcome by using Cox proportional hazards regression analysis.
Results
Surgical treatment included partial gastrectomy (28 dogs), Billroth I (9 dogs), subtotal gastrectomy (2 dogs), and submucosal resection (1 dog). Major postoperative complications occurred in 8 of 40 dogs, including septic peritonitis secondary to dehiscence in 4 dogs. The median progression free interval was 54 days, and the median survival time (MST) was 178 days (range, 1–1902). According to multivariable analysis results, experiencing an intraoperative complication was associated with an increased risk of death (hazard ratio HR 3.5, 95% CI 1.1–9.8, P = .005), and administration of adjuvant chemotherapy correlated with an improved survival (HR 0.4, 95% CI 0.2–0.9, P = .03).
Conclusion
In this population of dogs, MST exceeded historically reported data, major postoperative complication rates were comparable to established literature, and administration of adjuvant chemotherapy was associated with improved survival.
Clinical significance
Results from this study may be used to counsel owners more accurately regarding prognosis for dogs undergoing surgical excision for gastric carcinoma.
BACKGROUNDTransforming growth factor-β 1 (TGF-β1) participates in the synthesis and deposition of collagen. It has been implicated in fibrosis of tendons in wound-healing models but has never been ...studied in muscles with respect to distraction osteogenesis.
METHODSUsing a rabbit model of distraction osteogenesis, we distracted the left tibias of 36 New Zealand white rabbits at 0.75 mm/d for 20 days. To determine whether suramin, an antagonist of TGF-β, could aid in the prevention of fibrosis, we injected it into the anterior tibialis muscle 12 rabbits received low-dose suramin (50 mg), 12 received high-dose suramin (100 mg), and 12 received sham injections. Half of each group was killed at the end of distraction (day 24) and the other half at day 60. At the time of killing the rabbits, joint range of motion was measured, and strength and morphometric measures of the muscle were taken. Muscle was harvested and immunolabeled for TGF-β1. All findings were compared between study limbs and control (right) limbs.
RESULTSThe comparison failed to demonstrate improvements in the range of motion, and in strength or morphometric muscle development. Immunolabeling for TGF-β1 failed to show any staining in the intramuscular fibrosis. Paradoxically, muscle injected with high-dose suramin had the highest degree of fibrosis.
CONCLUSIONSWe conclude that TGF-β1 may not be the primary mediator of muscle fibrosis in distraction osteogenesis.
CLINICAL RELEVANCEInjection of suramin may not prevent contracture formation after distraction osteogenesis.
Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric ...patients undergoing cardiopulmonary resuscitation (CPR).
Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes ROSC) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects.
Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 95% CI: 0.55–2.36), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 0.43, 1.77), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26).
In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.
Abstract only
Introduction:
Extracorporeal cardiopulmonary resuscitation (ECPR) has been associated with improved outcomes compared to conventional CPR (CCPR) in children with underlying cardiac ...disease. There are limited data on ECPR survival outcomes in the non-cardiac population.
Hypothesis:
ECPR will be associated with improved survival to discharge in children without underlying cardiac disease with prolonged CPR.
Methods:
Retrospective cohort study using the AHA Get With The Guidelines® - Resuscitation registry of children (<18 years) without cardiac disease who received ≥30 minutes of CPR for in-hospital cardiac arrest between 2000-2020. Weighted propensity scores were used to balance ECPR and CCPR groups based on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model was used to estimate the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR relative to the index year of 2000.
Results:
Of 875 patients, 159 received ECPR and 716 received CCPR (median age 1 year, primary diagnosis respiratory insufficiency, median CPR duration 45 minutes for full cohort). Survival to discharge was similar between the ECPR group (21.4%) compared to the CCPR group (16.2%) in both the univariable analysis (p= 0.13) and the propensity-weighted multivariable logistic regression (aOR 1.44 CI 0.85-2.44, p= 0.173. The Bayesian model estimated an 85.1% probability of a positive effect of ECPR on survival to discharge. ECPR use increased over time (test for trend p<0.001).
Conclusion:
In children without cardiac disease who required ≥30 minutes of CPR, ECPR usage significantly increased in the last 20 years. Compared to CCPR, ECPR was not associated with a statistically significant increase in survival to discharge. However, a Bayesian model estimated weak evidence of a positive survival effect of ECPR.
Time from the onset of “low or no flow” indicators of cardiac failure to initiation of cardiopulmonary resuscitation is an important quality metric thought to improve the likelihood of survival and ...preservation of end organ function. We hypothesized that delays in initiation of chest compressions were under recognized during in-hospital resuscitation and aimed to develop a system which identifies the actual time of deterioration during cardiac events.
Retrospective review on prospectively identified resuscitation records and monitor data were compared. Return of spontaneous circulation, survival, and changes in functional status of patients pre- and post-events with chest compressions were collected as outcome measures.
Between October 2012 and April 2015, 59 events which met eligibility criteria occurred in either our pediatric cardiac or general pediatric intensive care units. The median time from event onset to initiation of chest compressions was 47s(s) (interquartile range (IQR) 28–80s) as assessed using monitor data, while the resuscitation record reported a median time of 0s (IQR 0–60s), reflecting the time from recognition to initiation of chest compressions. According to the resuscitation record, 81% vs. 63% of events achieved the quality standard of less than one minute depending on which review method was used (p=0.04).
There is a significant difference between time of deterioration to initiation of chest compressions and the time of recognition to initiation of chest compressions. Resuscitation records should be modified to include more information about the actual timing of patient deterioration.
The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a ...noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years.
Retrospective multicenter cohort study.
Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021.
Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest.
None.
Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 interquartile range: 0.2-7.0 year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 35-63 minutes. ECPR use increased over time ( p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis ( p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 95% CI, 0.84-2.40; p = 0.19). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge.
ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).
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