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Roth K, Darwish C, Keller MD, Hammer B, Ahmed-Winston S, Escalante E, Madrigal V, Patrick D, Diab Y, Grant C, Hanisch B, Kahn I, Khan S, Moudgil A, Wistinghausen B. Implementation of a tier system for IVIG indications to address IVIG shortage at a tertiary care pediatric medical center. Pediatr Blood Cancer 2024; 71:e30871. [PMID: 38279890 DOI: 10.1002/pbc.30871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Drug shortages are a common issue that healthcare systems face and can result in adverse health outcomes for patients requiring inferior alternate treatment. The United States recently experienced a national drug shortage of intravenous immunoglobulin (IVIG). Several reported strategies to address the IVIG and other drug shortages have been proposed; however, there is a lack of evidence-based methods for protocol development and implementation. OBJECTIVE To evaluate the efficacy of introducing a multidisciplinary task force and tier system of indications and to minimize adverse effects during a shortage of IVIG. METHODS Faculty members across disciplines with expertise in IVIG use were invited to participate in a task force to address the shortage and ensure adequate supply for emergent indications. A tier system of IVIG indications was established according to the severity of diagnosis, urgency of indication, and quality of supporting evidence. Based on inventory, indications in selected tiers were auto-approved. Orders that could not be automatically approved were escalated for task force review. RESULTS Overall, there were 342 distinct requests for IVIG during the study period (August 1, 2019 to December 31, 2019). All Tier 1 indications were approved. Of all requests, only 2.6% (9) of requests were denied, none of which resulted in adverse effects based on retrospective chart review. Seven patients who regularly receive IVIG had possible adverse effects due to dose reduction or spacing of treatment; however, each complication was multifactorial and not attributed to the shortage or tier system implementation alone. CONCLUSION Implementation of a multidisciplinary task force and tier system to appropriately triage high-priority indications for limited pharmaceutical agents should be considered in health institutions faced with a drug shortage.
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Affiliation(s)
- Kristina Roth
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Christina Darwish
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Michael D Keller
- Division of Allergy & Immunology, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Hammer
- Department of Pharmacy, Children's National Hospital, Washington, District of Columbia, USA
| | - Sameeva Ahmed-Winston
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, District of Columbia, USA
| | - Enrique Escalante
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Vanessa Madrigal
- Division of Intensive Care, Children's National Hospital, Washington, District of Columbia, USA
| | - DiAnthia Patrick
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Yaser Diab
- Division of Hematology & Oncology, Children's National Hospital, Washington, District of Columbia, USA
| | - Christina Grant
- Division of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Hanisch
- Division of Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
| | - Ilana Kahn
- Division of Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Sairah Khan
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Asha Moudgil
- Division of Nephrology, Children's National Hospital, Washington, District of Columbia, USA
| | - Birte Wistinghausen
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, District of Columbia, USA
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Shapiro MC, Boss RD, Donohue PK, Weiss EM, Madrigal V, Henderson CM. A Snapshot of Chronic Critical Illness in Pediatric Intensive Care Units. J Pediatr Intensive Care 2024; 13:55-62. [PMID: 38571989 PMCID: PMC10987218 DOI: 10.1055/s-0041-1736334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022] Open
Abstract
Children with chronic critical illness (CCI) represent the sickest subgroup of children with medical complexity. In this article, we applied a proposed definition of pediatric CCI to assess point prevalence in medical, cardiovascular, and combined pediatric intensive care units (PICUs), screening all patients admitted to six academic medical centers in the United States on May 17, 2017, for pediatric CCI (PCCI) eligibility. We gathered descriptive data to understand medical complexity and resource needs of children with PCCI in PICUs including data regarding hospitalization characteristics, previous admissions, medical technology, and chronic multiorgan dysfunction. Descriptive statistics were used to characterize the study population and hospital data. The study cohort was divided between PICU-prolonged (stay > 14 days) and PICU-exposed (any time in PICU); comparative analyses were conducted. On the study day, 185 children met inclusion criteria, 66 (36%) PICU-prolonged and 119 (64%) PICU-exposed. Nearly all had home medical technology and most ( n = 152; 82%) required mechanical ventilation in the PICU. The PICU-exposed cohort mirrored the PICU-prolonged with a few exceptions as follows: they were older, had fewer procedures and surgeries, and had more recurrent hospitalizations. Most ( n = 44; 66%) of the PICU-prolonged cohort had never been discharged home. Children with PCCI were a sizable proportion of the unit census on the study day. We found that children with PCCI are a prevalent population in PICUs. Dividing the cohorts between PICU-prolonged and PICU-exposed helps to better understand the care needs of the PCCI population. Identifying and studying PCCI, including variables relevant to PICU-prolonged and PICU-exposed, could inform changes to PICU care models and training programs to better enable PICUs to meet their unique needs.
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Affiliation(s)
- Miriam C. Shapiro
- Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States
- Center for Bioethics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Renee D. Boss
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Berman Institute of Bioethics, Baltimore, Maryland, United States
| | - Pamela K. Donohue
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Elliott M. Weiss
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, United States
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Vanessa Madrigal
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Carrie M. Henderson
- Department of Pediatrics, Division of Critical Care Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States
- Center for Bioethics and Medical Humanities, Jackson, Mississippi, United States
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Madrigal V, MacDuffie K, Paquette ET. Addressing Racism in the Healthcare Encounter: The Role of Clinical Ethics Consultants. The Journal of Clinical Ethics 2022. [DOI: 10.1086/jce2022333202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Shapiro JP, Anspacher M, Madrigal V, Lantos JD. Disposition Decisions in Cases of Medical Complexity and Health Inequity. Pediatrics 2022; 150:188525. [PMID: 35909152 DOI: 10.1542/peds.2021-055558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/24/2022] Open
Abstract
The question of optimal disposition for children with complex medical and social circumstances has long challenged the well-intentioned clinician. The coronavirus disease 2019 pandemic created unique difficulties for patients, families, and health care providers, in addition to highlighting long-standing racial and socioeconomic inequities in health care. In pediatric hospitals, necessary public health measures such as visitor restrictions shifted many shared decision-making processes such as discharge planning from complicated to impossible. Here, we present the case of a medically complex adult (with a long-standing pediatric condition) whose surrogate decision-maker objected to discharge to a long-term care facility because of restrictions and risks associated with the coronavirus disease 2019 pandemic. We offer the commentary of experts in clinical ethics, intensive care, inpatient subacute care, and palliative care. Our discussion includes analysis of the ethical considerations involved in the case, concrete guidance on steps toward an ethically permissible discharge, and suggestions for how a health equity lens can improve communication and decision-making for families who are victims of systemic racism and economic discrimination.
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Affiliation(s)
- Joseph P Shapiro
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Boston Medical Center, Boston, Massachusetts
| | - Melanie Anspacher
- Department of Hospital Medicine, Children's National Hospital, Washington, District of Columbia, and Medical Director, The HSC Pediatric Center, Washington, District of Columbia
| | - Vanessa Madrigal
- Department of Pediatrics, Division of Critical Care Medicine, and Director of Pediatric Ethics Program, Children's National Hospital, Washington, District of Columbia
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Enquist K, Madrigal V, McLaughlin K. Characterization of Putative Transcriptional Regulator Orf90. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r4320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Boss RD, Henderson CM, Weiss EM, Falck A, Madrigal V, Shapiro MC, Williams EP, Donohue PK. The Changing Landscape in Pediatric Hospitals: A Multicenter Study of How Pediatric Chronic Critical Illness Impacts NICU Throughput. Am J Perinatol 2022; 39:646-651. [PMID: 33075841 DOI: 10.1055/s-0040-1718572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pediatric inpatient bed availability is increasingly constrained by the prolonged hospitalizations of children with medical complexity. The sickest of these patients are chronic critically ill and often have protracted intensive care unit (ICU) stays. Numbers and characteristics of infants with chronic critical illness are unclear, which undermines resource planning in ICU's and general pediatric wards. The goal of this study was to describe infants with chronic critical illness at six academic institutions in the United States. STUDY DESIGN Infants admitted to six academic medical centers were screened for chronic, critical illness based on a combination of prolonged and repeated hospitalizations, use of medical technology, and chronic multiorgan involvement. Data regarding patient and hospitalization characteristics were collected. RESULTS Just over one-third (34.8%) of pediatric inpatients across the six centers who met eligibility criteria for chronic critical illness were <12 months of age. Almost all these infants received medical technology (97.8%) and had multiorgan involvement (94.8%). Eighty-six percent (115/134) had spent time in an ICU during the current hospitalization; 31% were currently in a neonatal ICU, 34% in a pediatric ICU, and 17% in a cardiac ICU. Among infants who had been previously discharged home (n = 55), most had been discharged with medical technology (78.2%) and nearly all were still using that technology during the current readmission. Additional technologies were commonly added during the current hospitalization. CONCLUSION Advanced strategies are needed to plan for hospital resource allocation for infants with chronic critical illness. These infants' prolonged hospitalizations begin in the neonatal ICU but often transition to other ICUs and general inpatient wards. They are commonly discharged with medical technology which is rarely weaned but often escalated during subsequent hospitalizations. Identification and tracking of these infants, beginning in the neonatal ICU, will help hospitals anticipate and strategize for inpatient bed management. KEY POINTS · 35% of inpatients with chronic critical illness are infants.. · Nearly 90% of these infants spend some time in an intensive care unit.. · 78% are discharged with medical technology..
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
- Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Elliott M Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
| | - Alison Falck
- Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa Madrigal
- Department of Pediatrics, Children's National Medical Center, Washington, Dist. of Columbia
| | - Miriam C Shapiro
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | - Pamela K Donohue
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Population and Families, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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7
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Madrigal V, MacDuffie K, Paquette ET. Addressing Racism in the Healthcare Encounter: The Role of Clinical Ethics Consultants. J Clin Ethics 2022; 33:202-209. [PMID: 36137202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Clinical ethicists move in different environments and interface with a variety of stakeholders, and are therefore uniquely positioned to answer the call for equity and anti-racism. We describe why a clinical ethicist should contribute to anti-racism efforts and describe general approaches for addressing racism across institutional contexts, including: (1) addressing racism as bedside clinical ethics consultant, (2) addressing wider lens of anti-racism work across multiple ethics consults over time, and (3) addressing racism at the organizational level.
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Affiliation(s)
- Vanessa Madrigal
- Director of the Pediatric Ethics Program, an Attending Physician in Pediatric Critical Care Medicine, Children's National Hospital, and is an Associate Professor at the George Washington University in Washington, District of Columbia USA.
| | - Kate MacDuffie
- Assistant Professor in the Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute and Department of Pediatrics, Division of Bioethics and Palliative Care, University of Washington School of Medicine, in Seattle, Washington USA.
| | - Erin Talati Paquette
- Associate Professor of Pediatrics and Associate Professor of Law (by courtesy) at Northwestern University Pritzker School of Law; Chair of the Ethics Advisory Board, Associate Director of Clinical and Organizational Ethics, and an Attending Physician, Pediatric Critical Care, at the Ann and Robert H. Lurie Children's Hospital of Chicago in Chicago, Illinois USA. epaquette@luriechildrens. org
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Walter JK, Madrigal V, Shah P, Kubis S, Himebauch AS, Feudtner C. The Impact of a Pediatric Continuity Care Intensivist Program on Patient and Parent Outcomes: An Unblinded Randomized Controlled Trial. J Pediatr Intensive Care 2021. [DOI: 10.1055/s-0041-1740360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Objectives We studied the impact of a standardized continuity care intensivists (CCIs) program on patient and family outcomes for long-stay patients in the pediatric intensive care unit (PICU), also assessing the intervention's acceptability and feasibility.
Methods A patient-level, unblinded randomized-controlled trial in a PICU at a large children's hospital. Participants included: (1) patients with ≥ 7 days PICU admission and likely to stay another 7 days; (2) their parents; (3) PICU attendings participating as continuity attendings; and (4) PICU attendings providing usual care (UC). We examined a bundled intervention: (1) standardized continuity attending role, (2) communication training course for CCI, and (3) standardized timing of contact between CCI and patient/family.
Results Primary outcome was patient PICU length of stay. Secondary outcomes included patient, parental, and clinician outcomes. We enrolled 115 parent-patient dyads (231 subjects), 58 patients were randomized into treatment arm and 56 into the UC arm. Thirteen attendings volunteered to serve as CCI, 10 as UC. No association was found between the intervention and patient PICU length of stay (p = 0.5), other clinical factors, or parental outcomes. The intervention met a threshold for feasibility of enrollment, retention, and implementation while the majority of providers agreed the intervention was acceptable with more efficient decision making. Thirty percent CCIs felt the role took too much time, and 20% felt time was not worth the benefits.
Conclusion CCI intervention did not impact patient or family outcomes. PICU attendings believed that the implementation of the CCI program was feasible and acceptable with potential benefits for efficiency of decision making.
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Affiliation(s)
- Jennifer K. Walter
- Department of Pediatrics at Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Vanessa Madrigal
- Department of Pediatrics, Pediatric Critical Care Medicine, Children's National Hospital and George Washington University, Washington, D.C., United States
| | - Parth Shah
- Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Sherri Kubis
- Cardiac Nursing at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Adam S. Himebauch
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Chris Feudtner
- Department of Pediatrics at Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, Pennsylvania, United States
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Weaver MS, Wiener L, Jacobs S, Bell CJ, Madrigal V, Mooney-Doyle K, Lyon ME. Weaver et al's Response to Morrison: Advance Directives/Care Planning: Clear, Simple, and Wrong (DOI: 10.1089/jpm.2020.0272). J Palliat Med 2020; 24:8-10. [PMID: 32865470 DOI: 10.1089/jpm.2020.0486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Meaghann S Weaver
- Division of Pediatric Palliative Care, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Shana Jacobs
- Division of Oncology, Children's National Medical Center, Washington, DC, USA
| | - Cynthia J Bell
- College of Nursing, Wayne State University, Detroit, Michigan, USA
| | - Vanessa Madrigal
- Pediatric Critical Care and Pediatric Ethics Program, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Kim Mooney-Doyle
- Department of Family and Community Health, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Maureen E Lyon
- Children's National Hospital/Center for Translational Science and George Washington School of Medicine and Health Sciences, Washington, DC, USA
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10
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Affiliation(s)
- Wynne Morrison
- Departments of Anesthesiology and Critical Care Medicine and Palliative Care, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Vanessa Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health Systems, Washington, DC
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Madrigal V, Walter JK, Sachs E, Himebauch AS, Kubis S, Feudtner C. Pediatric continuity care intensivist: A randomized controlled trial. Contemp Clin Trials 2019; 76:72-78. [PMID: 30468772 DOI: 10.1016/j.cct.2018.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Long-stay critically ill patients in the Pediatric Intensive Care Unit (PICU) may be at risk for inconsistencies in treatment plan, delay in plan progression, and patient/family dissatisfaction with communication. This article describes the development and evaluation of an intervention designed to improve continuity and communication delivered by continuity PICU attendings. METHODS AND ANALYSIS A randomized controlled trial of an intervention in one PICU that was randomized at the patient level. Eligible patients and their parents included those admitted to the PICU for longer than one week and were anticipated to remain for an additional 7 days. The intervention, a Continuity Care Intensivist (CCI), included early assignment of a continuity attending (separate from a regularly scheduled service attending), standardization of the continuity role to ensure consistent team and family contact and facilitate timely decision making, and enhancement of CCI communication skills. The outcomes evaluated were 1) patient PICU length of stay, ventilator-dependent days, and hospital acquired infections, 2) parental mood and satisfaction with PICU communication, and 3) intensivist perception of acceptability of intervention. Intention to treat analysis will be completed using multivariable linear regression to determine the impact of the intervention on outcomes. Lessons have been learned about the appropriate enrollment criteria for patients to allow for impact of continuity attending, frequent prognostic uncertainty in determining which patients will become longer stay in the PICU, and the difficulty of achieving timely initial contact of continuity attending with patients given the CCI's other commitments.
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Affiliation(s)
- Vanessa Madrigal
- Children's National Health System, Washington, DC, United States
| | - Jennifer K Walter
- Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Emily Sachs
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Adam S Himebauch
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sherri Kubis
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
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12
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Akopians A, Madrigal V, Fisch S, Ramirez E, Margolis D, Sarma M, Thomas M, Grogan T, Abbott D, Haykal R, Chazenbalk G, Dumesic D. Hyperandrogenism is associated with preferential fat deposition of visceral versus subcutaneous (SC) abdominal fat in lean polycystic ovary syndrome (PCOS) women. Fertil Steril 2016. [DOI: 10.1016/j.fertnstert.2016.07.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Cardoso RC, Veiga-Lopez A, Moeller J, Beckett E, Pease A, Keller E, Madrigal V, Chazenbalk G, Dumesic D, Padmanabhan V. Developmental Programming: Impact of Gestational Steroid and Metabolic Milieus on Adiposity and Insulin Sensitivity in Prenatal Testosterone-Treated Female Sheep. Endocrinology 2016; 157:522-35. [PMID: 26650569 PMCID: PMC4733129 DOI: 10.1210/en.2015-1565] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Prenatally testosterone (T)-treated sheep present metabolic disruptions similar to those seen in women with polycystic ovary syndrome. These females exhibit an increased ratio of small to large adipocytes, which may be the earliest event in the development of adult insulin resistance. Additionally, our longitudinal studies suggest the existence of a period of compensatory adaptation during development. This study tested whether 1) in utero cotreatment of prenatally T-treated sheep with androgen antagonist (flutamide) or insulin sensitizer (rosiglitazone) prevents juvenile insulin resistance and adult changes in adipocyte size; and 2) visceral adiposity and insulin sensitivity are both unaltered during early adulthood, confirming the predicted developmental trajectory in this animal model. Insulin sensitivity was tested during juvenile development and adipose tissue distribution, adipocyte size, and concentrations of adipokines were determined during early adulthood. Prenatal T-treated females manifested juvenile insulin resistance, which was prevented by prenatal rosiglitazone cotreatment. Neither visceral adiposity nor insulin sensitivity differed between groups during early adulthood. Prenatal T-treated sheep presented an increase in the relative proportion of small adipocytes, which was not substantially prevented by either prenatal intervention. A large effect size was observed for increased leptin concentrations in prenatal T-treated sheep compared with controls, which was prevented by prenatal rosiglitazone. In conclusion, gestational alterations in insulin-glucose homeostasis likely play a role in programming insulin resistance, but not adipocyte size distribution, in prenatal T-treated sheep. Furthermore, these results support the notion that a period of compensatory adaptation of the metabolic system to prenatal T exposure occurs between puberty and adulthood.
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Affiliation(s)
- Rodolfo C Cardoso
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Almudena Veiga-Lopez
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Jacob Moeller
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Evan Beckett
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Anthony Pease
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Erica Keller
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Vanessa Madrigal
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Gregorio Chazenbalk
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Daniel Dumesic
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
| | - Vasantha Padmanabhan
- Department of Pediatrics (R.C.C., A.V.-L., J.M., E.B., V.P.), University of Michigan, Ann Arbor, Michigan 48109; Department of Small Animal Clinical Sciences (A.P.), Michigan State University, East Lansing, Michigan 48824; and Department of Obstetrics and Gynecology (E.K., V.M., G.C., D.D.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095
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Chazenbalk G, Phan J, Madrigal V, Ding X, Li X, Dumesic D. Abnormal expression of genes governing adipogenesis and extracellular matrix (ECM) formation in subcutaneous (SC) abdominal adipose stem cells (ASCs) of lean polycystic ovary syndrome (PCOS) women. Fertil Steril 2015. [DOI: 10.1016/j.fertnstert.2015.07.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Dumesic D, Madrigal V, Ramirez E, Margolis D, Thomas A, Grogan T, Chazenbalk G. Structure-function relationships of subcutaneous (SC) abdominal adipocytes with metabolic function in lean polycystic ovary syndrome (PCOS) and normoandrogenic ovulatory women. Fertil Steril 2015. [DOI: 10.1016/j.fertnstert.2015.07.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Keller E, Chazenbalk GD, Aguilera P, Madrigal V, Grogan T, Elashoff D, Dumesic DA, Abbott DH. Impaired preadipocyte differentiation into adipocytes in subcutaneous abdominal adipose of PCOS-like female rhesus monkeys. Endocrinology 2014; 155:2696-703. [PMID: 24735327 PMCID: PMC4060192 DOI: 10.1210/en.2014-1050] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Metabolic characteristics of polycystic ovary syndrome women and polycystic ovary syndrome-like, prenatally androgenized (PA) female monkeys worsen with age, with altered adipogenesis of sc abdominal adipose potentially contributing to age-related adverse effects on metabolism. This study examines whether adipocyte morphology and gene expression in sc abdominal adipose differ between late reproductive-aged PA female rhesus monkeys compared with age-matched controls (C). Subcutaneous abdominal adipose of both groups was obtained for histological imaging and mRNA determination of zinc finger protein 423 (Zfp423) as a marker of adipose stem cell commitment to preadipocytes, and CCAAT/enhancer binding protein (C/EBP)α/peroxisome proliferator-activated receptor (PPAR)δ as well as C/EBPα/PPARγ as respective markers of early- and late-stage differentiation of preadipocytes to adipocytes. In all females combined, serum testosterone (T) levels positively correlated with fasting serum levels of total free fatty acid (r(2) = 0.73, P < .002). PA females had a greater population of small adipocytes vs C (P < .001) in the presence of increased Zfp423 (P < .025 vs C females) and decreased C/EBPα (P < .003, vs C females) mRNA expression. Moreover, Zfp423 mRNA expression positively correlated with circulating total free fatty acid levels during iv glucose tolerance testing (P < .004, r(2) = 0.66), whereas C/EBPα mRNA expression negatively correlated with serum T levels (P < .02, r(2) = 0.43). Gene expression of PPARδ and PPARγ were comparable between groups (P = .723 and P = .18, respectively). Early-to-mid gestational T excess in female rhesus monkeys impairs adult preadipocyte differentiation to adipocytes in sc abdominal adipose and may constrain the ability of this adipose depot to safely store fat with age.
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Affiliation(s)
- Erica Keller
- Departments of Obstetrics and Gynecology (E.K., G.D.C., P.A., V.M., D.A.D.) and Medicine Statistics Core (T.G., D.E.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California 90095-1740; and Department of Obstetrics and Gynecology and Wisconsin National Primate Research Center (D.H.A.), University of Wisconsin, Madison, Wisconsin 53715
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Madrigal V, Alonso J, Bureo E, Figols FJ, Salesa R. Fatal meningoencephalitis caused by Scedosporium inflatum (Scedosporium prolificans) in a child with lymphoblastic leukemia. Eur J Clin Microbiol Infect Dis 1995; 14:601-3. [PMID: 7588846 DOI: 10.1007/bf01690733] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A fatal case of meningoencephalitis caused by Scedosporium inflatum (Scedosporium prolificans) in a 5-year-old boy with acute myeloblastic leukemia who was given intrathecal treatment is reported. Itraconazole treatment was ineffective. The fungus was identified on brain sections at autopsy and was not observed in any other organ. As no other portal of entry was detected, meningoencephalitis may have originated via direct introduction of the fungus at therapeutic lumbar puncture.
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Affiliation(s)
- V Madrigal
- Department of Pediatrics, Hospital Universitario Marqués de Valdecilla, Spain
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Abstract
The case in study is a 13-year-old male with tubercular granuloma in the optic chiasma, affecting the right optic nerve and causing temporary loss of vision in that eye. Evoked visual potentials are performed and a first examination reveals that loss of vision was preceded by an alteration of response through the right optical path. The physiopathology is discussed and an evolutionary study of the lesion is made, evaluating the usefulness of EVPs in the diagnosis and follow-up in these patients.
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Affiliation(s)
- J Barrasa
- Servicio de Neurofisiología Clínica, Hospital Nacional Marqués de Valdecilla, Santander, Espagne
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Villazón Sahagún A, Corona A, Terrazas F, Madrigal V. [Basal energy expenditure in surgery]. Rev Gastroenterol Mex 1987; 52:103-11. [PMID: 3629108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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21
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Henriquez E, Madrigal V, Painter Cole L. [Vasectomy as an ambulatory procedure in El Salvador]. Rev Colomb Obstet Ginecol 1978; 29:43-7. [PMID: 715288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Madrigal V, Edelman DA, Goldsmith A. Laparoscopic sterilization as an outpatient procedure. J Reprod Med 1977; 18:261-4. [PMID: 141515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since June 1972, more than 2,000 laparoscopic sterilizations have been performed as outpatient procedures using neuroleptanalgesics. Electrocoagulation, spring-loaded clips or tubal rings were the methods used for tubal occlusion. All laparoscopies were performed in a family planning clinic. The surgical facilities were minimal and did not include general anesthesia equipment or a blood bank. The nearest hospital was about one-half mile from the clinic. The procedures were performed by a physician assisted by two paramedical personnel and a technician. Patients were scheduled to be at the clinic on the morning of the procedure and were discharged three to six hours after the procedure. Only one patient required hospitalization for treatment of a complication: her aorta was punctured during placement of the Tuohy needle. The patient was admitted to a local hospital and underwent laparotomy for repair; her subsequent recovery was uneventful. No bowel or bladder burns have occurred. Minor complications (emphysema of the abdominal wall, bleeding from the tubes, infections) have occurred in less than 4% of the patients. The results of this study indicate that laparoscopy in an outpatient clinic is safe and presents minimal additional risks to the patient if the surgeon is experienced.
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Madrigal V, Edelman DA, Henriquez E, Goldsmith A. A comparative study of spring-loaded clips and electrocoagulation for female sterilization. J Reprod Med 1977; 18:41-5. [PMID: 833799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The surgical, immediately postoperative and delayed postoperative complications and complaints associated with spring-loaded clips and electrocoagulation as techniques of tubal sterilization at laparoscopy were evaluated in a comparative study. Each of the two techniques was randomly assigned to 150 subjects. All sterilizations were performed as outpatient procedures. Subjects were followed-up during the first six weeks and again at about six months after sterilization. Rates of complications (surgical and early postoperative) were similar for the two procedures. None of the subjects required subsequent hospitalization. Technical difficulties at surgery were more frequent with the spring-loaded clip technique, principally as a result of mechnical problems with the prototype laparoscope and clip applicator. Postoperative pelvic and abdominal pain were reported by a significantly higher proportion of the patients when the spring-loaded clip was used (spring-loaded clips, 43.6%; electrocoagulation, 31.5%). At the six-month follow-up examination, rates of abnormal pelvic findings and changes in menstrual cycle formation were similar for the two techniques of tubal occlusion. There was one procedure failure among the electrocoagulation patients and none among the spring-loaded clip patients.
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Madrigal V, Goldsmith A. [Female sterilization by minilaparotomy in ambulatory patients: a modified technic]. Rev Colomb Obstet Ginecol 1976; 27:87-91. [PMID: 1027053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Madrigal V, Goldsmith A. A new technique for outpatient female sterilization. IPPF Med Bull 1975; 9:4. [PMID: 1213237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Madrigal V, Edelman DA, Goldsmith A. Male sterilization in El Salvador: A preliminary report. J Reprod Med 1975; 14:167-70. [PMID: 1095742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The expectation that male sterilization would not be an acceptable method of fertility control to the Latin American male has not been upheld in the initial phases of male sterilization programs in Colombia, Costa Rica, Guatemala, and El Salvador. On the contrary, in all of these programs and also at the Asociación Demográfica Salvadoreña, a free-standing, non-profit family planning clinic in San Salvador, the initial success has been impressive, with 180 men accepting sterilization during the first two years (February, 1972 to February, 1974). All sterilizations were performed by excising a 10-15 mm segment of each vas and ligating each vas end. Procedures were performed on an outpatient basis using a local anesthetic. Follow-up examinations were conducted at one week and three months after the procedure. Although complications were reported by 24.0% of the subjects at the one-week follow-up, the complications were minor: most were scrotal infections not requiring antibiotic therapy. Rates of complications were low for subjects returning for a three-month examination and semen test. Only one subject had a positive semen test.
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