Off-Pump "Clamp and Sew" Extracardiac Fontan With Inverted Bifurcated Graft for Dextrocardia With Heterotaxy Syndrome

Avoiding cardiopulmonary bypass during palliation of single ventricle has the advantages of minimizing transfusions, pulmonary vascular resistance, and avoiding the inflammatory response from cardiopulmonary bypass. It is however not always straightforward, and the technique may be faced with challenges.

Outcomes of Surgical Repair of Vascular Rings and Slings in Children: A Word for the Asymptomatic

Vascular rings (VRs) are rare aortic arch anomalies that may present with a wide variety of symptoms related to esophageal and/or airway compression. We reviewed our surgical experience in both symptomatic and asymptomatic children. All children (n = 58) who underwent surgical repair of VRs or slings (mean age 27.4 ± 45.60 months; 36 males [62%]) between March 2000 and April 2020 were included. The most common anatomic variant was a right aortic arch (RAA) with aberrant left subclavian artery (ALSCA) (n = 29; 50%). Kommerell's diverticulum was present in 23 of these patients (79%). The second most common variant was a double aortic arch (n = 22; 38%), followed by pulmonary artery sling (n = 4; 6%), RAA with mirror image branching and left ligamentum arteriosum (n = 3; 5.2%), and left aortic arch (LAA) with aberrant right subclavian artery (n = 1; 1.7%). One patient had a double ring with pulmonary artery sling and RAA with ALSCA. Symptoms were present in 42 patients (72%). Left lateral thoracotomy was the approach in 50 patients (86%), while sternotomy was used in 8 (14%). Symptomatic improvement occurred in the majority of symptomatic patients (93%). There was one perioperative mortality (1.7%) in the symptomatic group which was non-VR related. Morbidities included recurrent laryngeal nerve injury in three patients (5.2%) and transient chylothorax in two (3.4%). Persistence/recurrence of symptoms resulted in one early and one late reoperation. The mean follow-up was 3 ± 5 years. In the current era, VR repair in children including asymptomatic ones can be performed with excellent results. We recommend complete repair of RAA with aberrant LSCA by resection of Kommerell's diverticulum and translocation of the ALSCA to avoid recurrence.

Cadwaladerite, Al2(H2O)(OH)4·n(Cl,OH–,H2O), from Cerros Pintados, Chile, defined as a valid mineral species and the discreditation of lesukite

Cadwaladerite, described in 1941 as Al(OH)2Cl·4H2O, and lesukite, described in 1997 as Al2(OH)5Cl·2H2O, are very closely related chemically and structurally, but are found in very different environments. Cadwaladerite was found at the edge of a salar in Chile. Lesukite has been described from a volcanic fumarole and from burning coal seams. Both materials have cubic symmetry with a = 19.788 to 19.859Å. The crystal structure, common to both, consists of a rigid three-dimensional framework of edge- and corner-sharing Al(OH,H2O)6 octahedra that contains large interconnected cavities where loosely held Cl, OH, and H2O are located. The fact that Cl is loosely held within the structure is demonstrated by a dramatic reduction in Cl content after washing the material in distilled water, while the structural integrity is maintained. Herein, cadwaladerite is confirmed as a valid mineral species and lesukite is discredited because the only difference between the two materials is the loosely held extra-framework Cl, OH, and H2O. Cadwaladerite, Al2(H2O)(OH)4·n(Cl,OH,H2O) (Z = 48) takes precedence over lesukite based on the date of description. Material similar to cadwaladerite is found as a corrosion product on some types of nuclear fuel elements and is also closely related to the molecular species used in antiperspirant and water filtration.

Automated Audiovisual Feedback in Cardiopulmonary Resuscitation Training: Improving Skills in Pediatric Intensive Care Nurses

BACKGROUND

High-quality cardiopulmonary resuscitation is associated with improved survival and neurological outcomes after cardiac arrest. Unfortunately, health care professionals frequently do not perform resuscitation within guidelines after life-support training.

OBJECTIVES

To determine if brief intermittent training in cardiopulmonary resuscitation could improve nurses' skills to perform high-quality resuscitation 70% or more of the time during 2 minutes of cardiopulmonary resuscitation after 3 training sessions.

METHODS

In a prospective single-center quality improvement program, pediatric critical care nurses had monthly training in cardiopulmonary resuscitation. A portable manikin/defibrillator with a chest compression sensor was used to provide corrective audiovisual feedback to optimize resuscitation skills. Resuscitation was practiced on an adult manikin. Target goals were compression depth 2 in or greater at a compression rate of 100/min to 120/minute. Percentage of time in the target range and mean compression depth and rate were recorded. Data were collected every other month. The percentage of time both compression rate and depth were in the target range was compared among nurses with different total numbers of training sessions.

RESULTS

Of the 62 nurses who participated in the training, 48 had data collected. The median percentage of time in the target range improved from 29% with no training to 46% after 1 session, 54% after 2 sessions, 68% after 3 sessions, and 74% after 4 sessions (P = .001). Compression depth increased with the number of training sessions (P = .002).

CONCLUSIONS

This training program in cardiopulmonary resuscitation yielded significant skill improvement and retention.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Reducing variation in feeding newborns with congenital heart disease

OBJECTIVE

Enteral feeding is associated with decreased infection rates, decreased mechanical ventilation, decreased hospital length of stay, and improved wound healing. Enteral feeding difficulties are common in congenital heart disease. Our objective was to develop experience-based newborn feeding guidelines for the initiation and advancement of enteral feeding in the cardiothoracic intensive care unit.

DESIGN

This is a retrospective analysis of a quality improvement project.

SETTING

This quality improvement project was performed in a cardiothoracic intensive care unit.

PATIENTS

Newborns admitted to the cardiothoracic intensive care unit for cardiac surgery from January 2011 to May 2015 were retrospectively reviewed.

INTERVENTION

Newborn feeding guidelines for the initiation and advancement of enteral feeding were implemented in January 2012.

OUTCOME MEASURES

Guideline compliance and clinical variables before and after guideline implementation were reviewed.

RESULTS

Compliance with the guidelines increased from 83% in 2012 to 100% in the first two quarters of 2015. Preguidelines (January 2011-December 2011): 45 newborns underwent cardiac surgery; 8 deaths prior to discharge; 1 patient discharged from NICU, therefore, N = 36. Postguidelines (January 2012-May 2015): 131 newborns with 12 deaths, 12 admitted from home, 8 in the NICU, 3 on the floor preop, and 3 back transferred, therefore, N = 93. No difference in feeding preop (post 75% vs pre 69%; P = .5) or full po feeds at discharge (post 78% vs pre 89%; P = .2). Mesenteric ischemia was not statistically different postguidelines (post 6% vs pre 14%; P = .14). Length of hospital stay decreased postguidelines (post 27 + 17 d vs pre 34 + 42 d; P < .001).

CONCLUSIONS

Implementation of experience-based newborn feeding guidelines for initiation and advancement of enteral feeding in the cardiothoracic intensive care unit was successful in reducing practice variation supported by increasing guideline compliance. Percentage of patient's full oral feeding at discharge did not change. Length of hospital stay was reduced although cannot be fully attributed to feeding guideline implementation.

Improving Surveillance and Prevention of Surgical Site Infection in Pediatric Cardiac Surgery

BACKGROUND

Postoperative cardiovascular surgical site infections are preventable events that may lead to increased morbidity, mortality, and health care costs.

OBJECTIVE

To improve surgical wound surveillance and reduce the incidence of surgical site infections.

METHODS

An institutional review of surgical site infections led to implementation of 8 surveillance and process measures: appropriate preparation the night before surgery and the day of surgery, use of appropriate preparation solution in the operating room, appropriate timing of preoperative antibiotic administration, placement of a photograph of the surgical site in the patient's chart at discharge, sending a photograph of the surgical site to the patient's primary care physician, 30-day follow-up of the surgical site by an advanced nurse practitioner, and placing a photograph of the surgical site obtained on postoperative day 30 in the patient's chart.

RESULTS

Mean overall compliance with the 8 measures from March 2013 through February 2014 was 88%. Infections occurred in 10 of 417 total operative cases (2%) in 2012, in 8 of 437 total operative cases (2%) in 2013, and in 7 of 452 total operative cases (1.5%) in 2014.

CONCLUSIONS

Institution of the surveillance process has resulted in improved identification of suspected surgical site infections via direct rather than indirect measures, accurate identification of all surgical site infections based on definitions of the National Healthcare Safety Network, collaboration with all persons involved, and enhanced communication with patients' family members and referring physicians.

Increasing parental participation during rounds in a pediatric cardiac intensive care unit

BACKGROUND

Inviting parents of sick children to participate during the rounding process may reduce parents' anxiety and improve communication between the parents and the health care team.

OBJECTIVES

To increase the percentage of available parents invited to participate in morning rounds in a pediatric cardiothoracic intensive care unit (CTICU).

METHODS

Invitations to parents to participate in morning CTICU rounds were randomly audited from June 2012 to April 2014 (mean, 15 audits per month). From June 2012 to February 2013 (before intervention), 73% of parents available during morning rounds received an invitation to participate. From April 2013 to May 2013, the following interventions (family participation bundle) were implemented: (1) staff education, (2)"Invitation to Rounds" handout added to the parent welcome packet with verbal explanation, (3) bedside tool provided for parents to communicate desire to participate in rounds with the team, (4) reminder to invite parents added to nursing rounding sheet. Following interventions, family feedback was obtained by 1-on-1 (physician-parent) open-ended conversation.

RESULTS

From April 2013 to April 2014, 94% of parents available during morning rounds received an invitation to participate. Reasons for not participating: chose not to participate (63%), sleeping-staff reluctant to wake (25%), not English speaking (7%), breastfeeding (5%).

CONCLUSION

Implementation of a family participation bundle was successful in increasing invitations to parents to participate during morning rounds in the CTICU. Engagement of staff and addressing specific staff concerns was instrumental in the project's success.

Prenatal exposure to a repeated variable stress paradigm elicits behavioral and neuroendocrinological changes in the adult offspring: potential relevance to schizophrenia

Exposure to stress during gestation induces marked changes in the behavior of the affected offspring. Examining the consequences of prenatal stress may prove useful in understanding more about the origins of schizophrenia because a number of clinical investigations have suggested that developmental insults are associated with an increased incidence of schizophrenia. The purpose of these studies is to investigate the effects of stress during gestation on the behaviors of the adult male rat offspring with an emphasis on developing a heuristic animal model of schizophrenia. Pregnant female Sprague-Dawley rats were exposed to a novel variable stress paradigm during either the second or third week of gestation. Behavioral and neuroendocrinological consequences of prenatal stress exposure were evaluated in the male offspring on postnatal day 35 or 56. Prenatal stress exposure during the third week of pregnancy caused adult male rats to exhibit prolonged elevation in plasma glucocorticoid levels following acute exposure to restraint stress indicative of diminished glucocorticoid negative feedback. Similarly, exposure to stress during the third week of pregnancy elicited an enhanced locomotor response to the psychomotor stimulant amphetamine on postnatal day 56 but not on postnatal day 35. In addition, prepulse inhibition of the acoustic startle response was diminished across a range of prepulse stimulus intensities in prenatally stressed adult male rats. Similarly, prenatally stressed rats showed evidence of a disruption in auditory sensory gating as measured by the N40 response. Taken together, these findings suggest that prenatal stress exposure significantly changed many facets of adult rat behavior. Interestingly, the behaviors that are altered have been used to validate animal models of schizophrenia and therefore, suggest that this preparation may be useful to learn more about some aspects of the pathophysiology of schizophrenia.

Effects of acute and chronic clozapine on D-amphetamine-induced disruption of auditory gating in the rat

RATIONALE

Auditory gating deficits observed in patients with schizophrenia have been modeled in animals administered the indirect-acting monoaminergic agonist, D-amphetamine (AMPH). The atypical antipsychotic drug clozapine (CLOZ) reverses the disruption of auditory gating in schizophrenic patients. However, its effects on psychostimulant-induced deficits in animals have yet to be assessed.

OBJECTIVES

In the present series of experiments, an auditory evoked potential paradigm was used to: (a) confirm the ability of AMPH to alter auditory gating in the anesthetized rat, (b) specify the nature of the accompanying change(s) in evoked potential waveforms and (c) determine the effects of CLOZ administration on AMPH-induced alterations in auditory gating.

METHODS

We compared the effects of acute (5 mg/kg, i.p.) and chronic (28 days, 0.5 mg/ml in drinking water) CLOZ on AMPH-induced (1.8 mg/kg, i.p.) alterations in evoked potentials recorded in the hippocampus of anesthetized rats during presentation of a pair of identical tones. Gating was assessed by comparing the amplitude of conditioning and test responses in CLOZ and AMPH-treated rats.

RESULTS

The ratio of test to conditioning response amplitude (T/C ratio) was not altered by vehicle or CLOZ alone. However, T/C ratio was significantly increased following AMPH due to suppression of the conditioning response. Acute but not chronic CLOZ attenuated but did not prevent the increase in T/C ratio.

CONCLUSIONS

Qualitative differences between the idiopathic gating deficits observed in schizophrenic patients and AMPH-induced increases in T/C ratio in animals limit this models utility as a means of evaluating the ability of atypical antipsychotic drugs to restore normal sensory gating.

Micromolar brain levels of kynurenic acid are associated with a disruption of auditory sensory gating in the rat

Brain levels of kynurenic acid (KYNA), an endogenous antagonist of glycine(B)/NMDA and alpha-7 nicotinic acetylcholine receptors, are elevated in individuals with schizophrenia. Both receptors are broadly implicated in the pathophysiology of this disease, particularly in the deficits many patients show in filtering the sensorium. In the present study, we sought to determine whether elevated brain levels of KYNA disrupt auditory gating in anesthetized rats. A mid-latency evoked potential was recorded from the hippocampus in response to a pair of auditory tones. Gating was assessed by determining the ratio of the amplitude of test and conditioning responses (T/C ratio) in rats that had received KYNA's precursor L-kynurenine (KYN; 150 mg/kg, i.p.) together with probenecid (PBCD; 200 mg/kg, i.p.) 2 h prior to the start of the recording session. KYNA levels in the hippocampus of KYN+PBCD-treated rats were increased 500-fold, and accompanied by a significant increase in T/C ratio consistent with a disruption in sensory gating. PBCD alone increased hippocampal KYNA 12-fold, but did not significantly elevate T/C ratio. L-701,324 (3-30 mg/kg, i.v.), a centrally acting glycine(B) site antagonist, also failed to disrupt gating; however, large quantities of the competitive NMDA receptor antagonist DL-2-amino-5-phosphopentanoate (200 nmol, i.c.v.) markedly increased T/C ratio. Thus, while total blockade of NMDA receptors disrupts auditory gating, partial blockade achieved by antagonism of its glycine coagonist binding site does not. These observations indicate that the disruption in auditory processing in rats with greatly elevated KYNA levels is not attributable to the compound's antagonist actions at the glycine(B) receptor.