Joseph Hagan

Epidemiology and outcomes of dental trauma cases from an urban pediatric emergency department.

AIM The purpose of this retrospective study was to determine the outcomes of traumatized teeth treated in a pediatric emergency department. METHODS AND MATERIALS The records of pediatric patients presenting to the pediatric emergency department of a pediatric hospital over a 56-month period were reviewed and pertinent data were extracted. Treatment outcomes and contributing factors were analyzed for cases with greater than 6 months of follow up. RESULTS A total of 264 patient records (548 traumatized teeth) were investigated. The mean age of the children was 8.2 years and 62% were boys. The most common ages for dental trauma were between 2-4 years and 8-10 years. Permanent dentition comprised 53% of the traumatized teeth. Extrusive and lateral luxations (29.5%) were the most common injuries encountered. Two hundred and thirty seven teeth (43%) presented for follow-up visits, and the mean duration of follow up was 55.6 days. The number of cases with more than 6 months of follow up decreased to 122 (22%). Of these, 31 (6%) teeth were extracted at the time of injury. Outcomes were ascertained for the remaining 91 (17%) teeth. Emergency dental treatment led to uncomplicated retention of teeth beyond 6 months in 58% of these cases. Luxation injuries had a higher success rate than avulsions (P = 0.046). CONCLUSIONS After receiving emergency dental care in the emergency department, 43% of the teeth presented for follow-up dental care and only 22% were followed up for greater than 6 months. Emergency department treatment translated to successful retention of teeth in 58% of the cases with documented follow up. Severe periodontal injuries resulted in treatment complications.

Development and Evaluation of the Barriers to Nurses’ Participation in Research Questionnaire at a Large Academic Pediatric Hospital

The purposes of this study were to survey nurses at a large pediatric hospital to examine barriers to nursing research and to develop the Barriers to Nurses’ Participation in Research Questionnaire (BNPRQ) in preparation for its use at other institutions. The BNPRQ was created and refined through iterative pilot testing. Exploratory factor analysis was applied, and composite scores were computed for the identified factors. The two latent factors “Research Resources” and “Personal Relevance of Research” were extracted. The independent item “lack of time to do research” represented the largest barrier to research. Factor and item scores differed according to subject characteristics. Findings from this study will be used to create targeted interventions to reduce barriers to research participation prevalent in specific groups of nurses. By using the BNPRQ developed in this study, researchers and administrators at other institutions can identify and address barriers to research among their nurses.

Use of Vasopressin in Neonatal Intensive Care Unit Patients With Hypotension

OBJECTIVE To evaluate the safety and efficacy of vasopressin for the treatment of hypotension in patients admitted to neonatal intensive care units (NICUs). METHODS Vasopressin use in 69 infants admitted to our NICU between 2011 and 2014 was examined. Data evaluated included demographics; serum creatinine, sodium, and lactate concentrations; urine output; and systolic, diastolic, and mean blood pressures (BPs). Parameters prior to vasopressin use were compared to those at maximum dose. RESULTS Vasopressin use was associated with increased urine output (p < 0.05), and increased systolic (p < 0.0005), diastolic (p < 0.01), and mean (p < 0.001) BP. There were no differences in sodium or lactate concentrations before vs during infusion; vasopressin use was not associated with hyponatremia (sodium < 130 mEq/L) at the maximum dose. CONCLUSIONS Vasopressin for the treatment of neonatal hypotension appears safe and was efficacious in raising BP. These data suggest that vasopressin could be considered a viable option in the treatment regimen in hypotensive infants in the NICU.

Bleeding Complications and Mortality in Neonates Receiving Therapeutic Hypothermia and Extracorporeal Membrane Oxygenation

Abstract Objective The objective of this study was to compare complications and mortality in neonates with hypoxic ischemic encephalopathy (HIE) on extracorporeal membrane oxygenation (ECMO) who did and did not receive therapeutic hypothermia (TH). Study Design The Extracorporeal Life Support Organization registry was queried from 2005 to 2013 to identified infants with HIE. Infants ≤30 days of age with HIE on respiratory ECMO were included. Fishers exact test and the Wilcoxons rank‐sum test were used to compare neonates with and without TH. Logistic regression was used to examine the association of TH with complications and mortality. Results There were no difference between neonates with HIE who did (n = 78) and did not (n = 109) receive TH in demographics, severity of illness, complications, and mortality (p = 0.21). Conclusion No differences in complications or mortality in neonates with HIE and respiratory ECMO were observed between those who did and did not receive TH. We suggest that for neonates requiring respiratory ECMO who also have HIE, TH is not contraindicated.

Enamel surface roughness of preferred debonding and polishing protocols

Objective This study investigated the surface roughness of enamel after debonding and instrumentation with commonly used methods. Methods Part I: a survey was sent to active members of the American Association of Orthodontists to determine popular bonding, debonding, and polishing protocols. Part II: brackets were bonded to the buccal surface of 30 extracted human premolar teeth. After debonding, residual adhesive was removed with 12-, 16-, and 20-fluted titanium carbide burs as based upon the survey results. The teeth were scanned with a surface profilometer for surface roughness. Part III: the teeth were further polished using a Reliance Renew polishing point or a prophy cup with pumice and rescanned for surface roughness. Results Part I: the majority of respondents used a generic bracket-removing plier to remove fixed appliances (53%) and a high-speed handpiece for adhesive removal (85%). The most popular bur was a 12-fluted carbide bur without water spray. The majority of respondents used pumice paste and/or Reliance Renew points after adhesive removal. Part II: there was a significant difference in enamel surface roughness when 12-, 16-, and 20-fluted carbide burs were compared via surface profilometry. Part III: further polishing with a Reliance Renew point or a prophy cup and pumice did not provide a significantly smoother surface. Conclusions The results show large variation in debonding and polishing techniques. Creating a smooth enamel surface is equally possible with 12- or 20-fluted carbide burs. Further polishing with pumice and prophy cup or Renew point does not provide an enamel smoother surface.

Evaluation of opioid prescribing after rescheduling of hydrocodone-containing products

Purpose. Institutional prescribing trends of hydrocodone‐containing products (HCPs) before and after the Drug Enforcement Administrations rescheduling of HCPs were evaluated. Methods. A retrospective evaluation was performed on 6 oral opioid analgesics on the hospital formulary that were prescribed to patients treated at Texas Childrens Hospital and Pavilion for Women for the 6 months before and after the rescheduling of HCPs on October 6, 2014. Patients were eligible for inclusion if they were prescribed any of the following oral agents: HCPs (e.g., hydrocodone with acetaminophen), codeine‐containing products (e.g., codeine, codeine with acetaminophen), morphine, hydromorphone, oxycodone‐containing products (e.g., oxycodone, oxycodone with acetaminophen), and tramadol. Results. During the 12‐month study period, a total of 38,928 inpatient orders and outpatient prescriptions were processed for the studied agents in both locations; the majority were orders for inpatients. An overall reduction in the total number of opioid prescriptions was observed after the rescheduling of HCPs. Substantial increases in the proportional use of codeine were observed in all 4 settings after HCP rescheduling. Data for each of the agents revealed a shift in prescribing patterns centered along the HCP rescheduling date of October 6, 2014, and revealed a decrease in HCP use across all areas with an accompanying increase in codeine‐containing products, oxycodone‐containing products, and tramadol. Conclusion. The rescheduling of HCPs resulted in a reduction in HCP prescriptions but was accompanied by increases in the use of codeine‐containing products and tramadol in all settings.

Interrater Reliability of the Braden and Braden Q by Skin Champion Nurses

Abstract The interrater reliability of the Braden Q skin risk assessment scale has never been reported. The purpose of the study was to assess the interrater reliability among pediatric Skin Champion (SC) nurses with the use of the Braden and Braden Q scales. The pilot study included 16 paired SC nurses. Each pair of nurses attempted to assess 8 patients using the Braden and Braden Q scales. However, patient care requirements at the time of the study assessments limited the number slightly. The actual number of assessments with the Braden scale was n = 52 and the Braden Q was n = 63. The Intra‐class Correlation Coefficient (ICC) for the Braden scale was 0.894, 95% confidence interval (CI) (0.823, 0.938), which is excellent agreement. The ICC for the Braden Q was 0.726, 95% CI (0.585, 0.824), which is fair to good agreement. Among the six subcategories on the Braden scale, mobility and activity had higher agreement scores among the SC nurses. Among the seven subcategories on the Braden Q scale, mobility and sensory perception had higher agreement scores. Nutrition and friction/shear subcategories on both scales had the lowest agreement scores. Subcategories with the lowest agreement usually have the greatest measurement error. Possible sources of error include unclear definitions of scoring criteria, different clinical data pulled from different locations in the chart. Error can be reduced by clarifying the subcategory definitions and standardizing the data used for the assessment and the location of each data point in the EMR. A high interrater agreement is the goal because it provides confidence that the scale is used reliably to identify high risk patients who require additional care to prevent harmful events. HighlightsThe purpose of this study was to assess the interrater reliability among pediatric Skin Champion nurses with the use of the Braden and Braden Q skin risk assessment scales.The ICC for the Braden scale was 0.894, which indicated excellent agreement. Among the six subcategories, mobility and activity had the highest agreement scores.The ICC for the Braden Q scale was 0.726 which indicated fair to good agreement. Among the seven subcategories, mobility and sensory perception had the highest agreement scores.Nutrition and friction/shear subcategories had the lowest agreement scores on both scales. Lower agreement indicates greater measurement error.Disagreement error can be reduced by clarifying the Braden and Braden Q subcategory definitions and standardizing the location of the data pulled to score each item on the scales.

Evaluating reflex red blood cell transfusion thresholds in neonatal extracorporeal membrane oxygenation: LETTERS TO THE EDITOR

We read with interest the article by Sawyer and colleagues that found in neonatal extracorporeal membrane oxygenation (ECMO), a lower reflex red blood cell (RBC) transfusion threshold (hematocrit [Hct] of 35% vs. 40%) is associated with fewer transfusions and no apparent differences in patient outcomes and complication rates. We praise the authors for their attempt to address a topic that is inadequately investigated; however, we feel compelled to highlight the major limitations of their study, which received only a brief comment by the accompanying editorial. The 2014 Extracorporeal Membrane Oxygenation (ELSO) guidelines acknowledge that “thresholds for the transfusion of PRBCs vary from center to center and by type of patient, but are generally given as needed to replace any blood loss and maintain a near normal to normal hematocrit (>35-40%).” Given that the normal Hct for late preterm and term neonates is approximately 50%, many centers choose a trigger level for reflex RBC transfusion as 40%. One might speculate that a higher Hct, although normal in the newborn and vital for life in utero given the low pO2 and fetal hemoglobin with its greater affinity for oxygen, is not as relevant in the early postnatal period for a neonate infant on ECMO. The ECMO circuit is primed with adult blood that has a lower affinity for oxygen than fetal blood and a greater capacity to unload oxygen at the tissue level and hence a lower reflex RBC transfusion level might be acceptable. However, this speculation would need to be tested with appropriately designed studies to address the author’s stated aim. The authors describe their study as a “retrospective cohort study,” but the design used would be more accurately described as a quasi-experimental study with a preand postintervention comparison. Retrospective cohort studies are observational studies that look backward in time with groups defined by exposure status, whereas a preand postintervention quasi-experimental study design compares outcomes before versus after implementation of an intervention. Preand postintervention comparisons are susceptible to biased inference due to the effects of potentially confounding variables, including changes in practice over the time span studied. This could be supported by the fact that the total ECMO run time was lower in the latter period. Attempts to adjust for relevant covariates should be made when comparing interventions that are not randomized, but the low incidence of hematologic complications observed in the study, coupled with the low sample size (n 5 37 for Hct < 40 and n 5 35 for Hct < 35) precludes conducting meaningful multivariable regression analyses to compare groups after adjustment, because there are not enough data available to simultaneously estimate multiple independent variables’ associations with the rare outcomes examined. In fact, even the unadjusted group comparisons have very low statistical power thereby creating a high probability of making a Type II error where a false null hypothesis is not rejected. An equivalence study design would be needed to show that the two groups’ complication rates are equal within some margin of error deemed clinically negligible. For these reasons, the authors’ interpretation that the intervention “does not appear to alter complication rates or patient outcomes for neonates receiving ECMO support” is valid as an initial observation, but should not be considered confirmation of safety without further data. For an effective intervention, we would like to see at least a 25% reduction in “any complication” (baseline is 43.2%) and a lengthening of the first circuit life by at least 10% (baseline 156.9 6 48.7 hr). We would consider these changes to be clinically meaningful effects that differ from mere statistical significance. Assuming a 43.2% baseline rate of any complication, a 25% reduction would yield a postintervention complication rate of 32.4%, which would necessitate 335 patients per group to provide 80% statistical power to detect a difference at the 5% significance level. Thirty-seven patients per group only provides 10% statistical power to detect a difference in these complication rates. In other words, if these are the true rates of any complication in the two groups, with 37 patients per group there is a 90% probability of not detecting a significant difference between the two groups at the 5% significance level. For first circuit life, a 10% increase would yield a postintervention mean of 172.6 hours. Optimistically assuming a pooled standard deviation of 48.7 hours as observed in the preintervention group, 153 patients per group would be needed to provide 80% statistical power to detect this difference at the 5% significance level. Thirty-seven patients per group yields only 27% power to detect a 10% change in duration of first circuit life. Using the postintervention standard deviation of 89.1 hours would further reduce the power to detect meaningful differences. In conclusion, while we agree with the authors regarding the inherent risks of blood transfusions, we caution against using these results to change clinical practice without additional research testing the safety of lower thresholds.

Prophylactic Dextrose Gel Does Not Prevent Neonatal Hypoglycemia: A Quasi-Experimental Pilot Study

Objective To test the hypothesis that prophylactic dextrose gel administered to newborn infants at risk for hypoglycemia will increase the initial blood glucose concentration after the first feeding and decrease neonatal intensive care unit (NICU) admissions for treatment of asymptomatic neonatal hypoglycemia compared with feedings alone. Study design This quasi‐experimental study allocated asymptomatic at‐risk newborn infants (late preterm, birth weight <2500 or >4000 g, and infants of mothers with diabetes) to receive prophylactic dextrose gel (Insta‐Glucose; Valeant Pharmaceuticals North America LLC, Bridgewater, New Jersey); other at‐risk infants formed the control group. After the initial feeding, the prophylactic group received dextrose gel (0.5 mL/kg) rubbed into the buccal mucosa. The blood glucose concentration was checked 30 minutes later. Initial glucose concentrations and rate of NICU admissions were compared between the prophylactic group and controls using bivariate analyses. A multivariable linear regression compared first glucose concentrations between groups, adjusting for at‐risk categories and age at first glucose concentration. Results There were 236 subjects (72 prophylactic, 164 controls). The first glucose concentration was not different between the prophylactic and control groups in bivariate analysis (52.1 ± 17.1 vs 50.5 ± 15.3 mg/dL, P = .69) and after adjusting for covariates (P = .18). Rates of NICU admission for treatment of transient neonatal hypoglycemia were 9.7% and 14.6%, respectively (P = .40). Conclusions Prophylactic dextrose gel did not reduce transient neonatal hypoglycemia or NICU admissions for hypoglycemia. The carbohydrate concentration of Insta‐Glucose (77%) may have caused a hyperinsulinemic response, or alternatively, exogenous enteral dextrose influences glucose homeostasis minimally during the first few hours when counter‐regulatory mechanisms are especially active. Trial registration ClinicalTrials.gov: NCT02523222.

Characteristics of Isolated Ventricular Septal Defects Less Likely to Close In Utero: Characteristics of Isolated Ventricular Septal Defects Less Likely to Close In Utero

To determine the characteristics of fetal ventricular septal defects (VSDs) that will be less likely to close prenatally.