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Background As survival rates in neonates with congenital heart disease have improved, research has shown they are at an increased risk for brain injury and neurodevelopmental delay. One intervention shown to have a positive impact on the development in premature and full-term newborns, as well as a positive impact on mother-infant relationship, is kangaroo care (KC). There is limited evidence to support the use of KC in infants with congenital heart disease, some of who may also be premature. Purpose The purpose of this study was to examine the safety and feasibility of introducing KC for neonates with congenital heart disease in the pediatric cardiac intensive care unit. Methods A descriptive observational feasibility study was employed to evaluate the safety and efficacy of KC for this population. Results There were 25 neonates included with 60 sessions of KC. There were no adverse events including line and tube dislodgments and physiological instability related to the use of KC. Implications for practice This study found KC to be safe and feasible for neonates with KC. Implications for research This is the first study examining the feasibility and safety of KC in this vulnerable population of neonates. Further research should be conducted using a quasi-experimental design to investigate neurodevelopmental outcomes with a larger sample of patients.

Background Pediatric patients undergoing cardiac catheterization procedures are required to lie flat for 4 hours for femoral venous access and 6 hours for femoral arterial access. Authors of research in adults suggest the flat time for the same access can be safely reduced to 1.5 to 2 hours post procedure. No literature was found that flat times could be safely reduced for pediatric patients. Objective The purpose of this study was to determine whether decreased flat time for the post-cardiac catheterization pediatric patient would impact the incidence of site bleeding, additional sedation, and the need for a critical care admission. Methods A randomized controlled trial was designed and participants were randomly assigned to experimental or control group. The experimental group reduced flat times to 2 hours for venous and 4 hours for arterial. The control group was standard care of 4 hours for venous and 6 hours for arterial. Results A total of 119 participants were enrolled, 60 in the experimental group and 59 in the control group. Results suggest no difference in the incidence of site bleeding (P = .999), additional sedation (P = .653), or need for a critical care admission. Conclusions For pediatric patients undergoing arterial or venous cardiac catheterizations, flat times can safely be reduced without increasing site bleeding, additional sedation, or critical care admissions.

Purpose The purpose of this study was to investigate optimal intraoperative combinations of analgesia for children undergoing strabismus surgery. Design A randomized controlled trial was employed to compare the difference in pain after administration of hydromorphone versus fentanyl. Methods Participants were randomly assigned to either arm of the study. Pain was measured by the revised Faces, Legs, Activity, Cry, and Consolability Scale (rFLACC) tool postoperatively, and the parent was asked about the presence or absence of pain after discharge. Findings A total of 135 children were included in the study. The rFLACC pain score was found to be significantly higher postoperatively among patients receiving fentanyl (P = .011). Pain after discharge was reported more often among patients who received fentanyl (P Conclusions Results of this study can be used to change practice to minimize the pain levels both postoperatively and after discharge for children undergoing strabismus surgery.

OBJECTIVE To determine the association of repetitive subconcussive head impacts with functional outcomes in primary and high school tackle football players. SETTING Youth football fields and an outpatient sports neurology clinic. PARTICIPANTS A total of 112 primary school (n = 55, age 9-12 years) and high school (n = 57, age 15-18 years) football players. DESIGN A prospective cohort study. MAIN MEASURES Helmet-based sensors were used to record head impacts during practices and games during the 2016 football season. Impact g-forces were summed to yield a measure of cumulative impact. History of self-reported premorbid medical diagnoses was obtained preseason. Players completed assessments of a variety of outcomes both pre- and postseason: neuropsychological test performance, symptoms, vestibular and ocular-motor screening, balance, parent-completed attention-deficit hyperactivity disorder (ADHD) symptoms, and self-reported behavioral adjustment. RESULTS Average cumulative impact was 3700 (standard deviation = 2700) g-forces for the season and did not differ between age groups (P = .594). Cumulative impact did not predict pre- to postseason change scores on any outcome measures (all P > .05). Instead, younger age group and reported history of premorbid ADHD predicted change scores on several cognitive testing measures and parent-reported ADHD symptoms, while reported history of premorbid anxiety and depression predicted change scores on symptom reporting. CONCLUSIONS In youth tackle football, subconcussive head impacts sustained over the course of a single season may not be associated with neurocognitive functional outcomes. The absence of a significant association may reflect the relatively short follow-up interval, and signals the need for studies across multiple seasons.

BACKGROUND: Obesity presents an additional challenge to the procedure of and recovery from kidney transplantation. As the prevalence of transplant candidates with an elevated body mass index (BMI) grows, researchers need to examine and quantify the increased risks and additional costs associated with the full spectrum of body composition. STUDY DESIGN: A retrospective cohort study design was used. SETTING & PARTICIPANTS: Data from a private health insurance provider were linked with records from the Organ Procurement and Transplantation Network to examine costs and health outcomes following kidney transplantation. FACTOR: BMI was used to predict costs and outcomes. OUTCOMES: The primary outcome of interest was posttransplant cost defined as insurance charges. Secondary outcomes of interest included delayed graft function, graft failure, patient survival, and length of transplant hospitalization. MEASUREMENTS: Categories of BMI followed selected cutoffs from World Health Organization International Classifications. Charges from recipient dialysis center, health providers, and treatment centers following transplant were summed during transplant hospitalization as well as each of three years following transplantation. RESULTS: Rates of graft failure were significantly increased for underweight, overweight, obese, and morbidly obese recipients. Recipients with elevated BMI had a significantly longer length of transplant hospitalization and an increased rate of delayed graft function. LIMITATIONS: Our analysis was limited to the quality and availability of the data included in the registry. Though inexpensive and easy to calculate, BMI may not be the best measure of body composition. Finally, BMI measurement is cross-sectional at time of transplant thereby limiting the potential for fluctuation of BMI before and after transplantation. CONCLUSIONS: The study results highlight the exponential concern associated with non-normal BMI for kidney transplant recipients. Transplant centers and insurance companies should consider funding weight management programs for transplant candidates as a means of obtaining preferred BMI and reducing costs associated with follow-up care.

BACKGROUND A practice was changed to elevate the head of bed from day 1 to day 3 on children after selective dorsal rhizotomy (SDR) surgery to improve pain control. Multiple methods to address pain post SDR include a continuous epidural infusion, medication administration, and repositioning/distraction. The length of time for the patient to remain flat was increased to potentially improve pain management. However, no studies in the literature were found to support the practice change. Nurses inquired whether this change resulted in optimal pain control. The primary research aim was to determine whether the change in positioning resulted in a difference in pain control. METHODS A retrospective cohort design was used to compare pain medication administered before and after the practice change. Patients between the ages of 2 and 15 years and admitted to the neuroscience unit after SDR surgery were included. Data were electronically retrieved to record the amount of medications given for pain. Descriptive and univariate statistics were used to detect differences. RESULTS The retrospective component of the study analyzed a total of 385 patients. There were no statistically significant differences between the number of intermittent doses of medication administered for pain between the 2 groups (P = .661). DISCUSSION Results support return to practice of 1 day of flat time. Nurses perceive that lying flat contributes to child and parent anxiety and limits options for distraction; therefore, decreasing flat time may lower anxiety without affecting pain control. These results are limited to postsurgical SDR patients but have implications for postoperative positioning and pain management. On the basis of these results, the neurosurgeon changed practice to zero days of flat time.

Purpose Lay consultations can facilitate or impede healthcare. However, little is known about how lay consultations for symptom evaluation affect treatment decision-making. The purpose of this study was to explore the role of lay consultations in symptom evaluation prior to hospitalization among patients with heart failure. Methods Semi-structured interviews were conducted with 60 patients hospitalized for acute decompensated heart failure. Chi-square and Fisher's exact tests, along with logistic regression were used to characterize lay consultations in this sample. Results A large proportion of patients engaged in lay consultations for symptom evaluation and decision-making before hospitalization. Lay consultants provided attributions and advice and helped make the decision to seek medical care. Men consulted more often with their spouse than women, while women more often consulted with adult children. Conclusions Findings have implications for optimizing heart failure self-management interventions, improving outcomes, and reducing hospital readmissions.

Background Patients with heart failure (HF) are at heightened risk for acute exacerbation requiring hospitalization. Although timely reporting of symptoms can expedite outpatient treatment and avoid the need for hospitalization, few patients recognize and respond to symptoms until acutely ill. Objective The purpose of this study was to explore patients' perceptions of symptoms and self-care behaviors for symptom relief, leading up to a HF hospitalization. Methods To examine prehospitalization symptom scenarios, semistructured interviews were conducted with 60 patients hospitalized for acute decompensated HF. Results Thirty-seven patients (61.7%) said that they had a sense that "something just wasn't quite right" before their symptoms began but were unable to specify further. Signs and symptoms most often recognized by the patients were related to dyspnea (85%), fatigue (53.3%), and edema (41.7%). Few patients interpreted their symptoms as being related to worsening HF and most often attributed symptoms to changes in diet (18.3%) and medications (13.3%). Twenty-six patients (43.3%) used self-care strategies to relieve symptoms before hospital admission. More than 40% of the patients had symptoms at least 2 weeks before hospitalization. Conclusions Despite the wide dissemination of HF evidence-based guidelines, important components of symptom self-management remain suboptimal. Because most of HF self-management occurs in the postdischarge environment, research is needed that identifies how patients interpret symptoms of HF in the specific contexts in which patients self-manage their HF. These findings suggest the need for interventions that will help patients expeditiously recognize, accurately interpret, and use appropriate and safe self-care strategies for symptoms.

Purpose The purpose of this study was to determine if implementation of the discharge specialist role improves family perception of discharge readiness and determines whether the use of the role decreases the number of tasks needing completion on the day of discharge. Design and Methods A prospective descriptive study was designed to compare parent readiness for discharge from two groups of participants. One group had a discharge specialist the day of discharge. The other group did not have the assistance of the discharge specialist on the day of discharge. Participants were contacted after discharge and surveyed on their perception of readiness for discharge based on a modified version of the Care Transitions Method Survey. Patient responses were either Strongly Agree or Less than Strongly Agree. Results A total of 60 patients (30 in each group) were analyzed. There were no statistically significant differences in demographic variables between the two groups. The overall average score of the composite proportion responding with Strongly Agree was higher among caregivers using a discharge specialist (Mean = 88.2) as compared to those without (Mean = 55.9, U = 157.0, p Conclusion The use of a discharge specialist on the day of discharge resulted in a higher parent perception of discharge readiness in this sample of children with complex cardiac diagnosis. Practice Implications The use of a discharge specialist in the heart center can assist with the successful transition from hospital to home. Future research should examine the effect of the discharge specialist on hospital re-admission rates and clinical outcomes.

Importance Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices. Objective To compare the effect of 3 low-cost reminder devices on medication adherence. Design, Setting, and Participants This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient’s targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population. Main Outcomes and Measures The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants. Results Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results. Conclusions and Relevance Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence. Trial Registration clinicaltrials.gov Identifier:NCT02015806

OBJECTIVES: Information is lacking regarding recognition and treatment of overweight and obesity in children hospitalized for asthma. The study objectives were to determine the current practice of recognition, diagnosis, and treatment of overweight and obesity for children hospitalized for asthma and to describe demographic, asthma, and weight characteristics for these patients. METHODS: A retrospective record review was conducted for children admitted to the hospital with asthma in 2012. Charts were reviewed for evidence of recognition, diagnosis, and treatment of overweight and obesity. Subjects were classified into age-adjusted Centers for Disease Control and Prevention weight categories based on BMI percentile and chronic asthma severity categories according to National Asthma Education and Prevention Program guidelines. RESULTS: A total of 510 subjects aged 3 to 17 years were studied. Obesity was present in 19.6% and overweight in 13.3% of subjects. BMI percentile was recorded in only 3.3% of all charts, in only 11% of subjects with obesity, and in 0% of subjects with overweight. BMI percentile was documented more often in subjects with severe obesity (P = .013) and with moderate to severe persistent asthma (P = .035). Only 9 of 168 subjects who were overweight or obese (5.6%) were given a discharge diagnosis indicating overweight or obesity, and 14 (8.3%) received treatment. Chronic asthma severity differed by BMI weight category (P < .001), with a significant relationship between obesity status and chronic asthma severity in older subjects (P = .033). There were no differences in severity of acute episodes based on weight group. CONCLUSIONS: Overweight and obesity were underrecognized, underdiagnosed, and undertreated in children hospitalized for asthma.

Despite traditional education regarding the Asthma Action Plan (AAP), providers in the inpatient setting of a pediatric hospital reported lack of knowledge regarding the AAP and lack of confidence in teaching the AAP to patients and families. The purpose of this study was to assess the effect of a pediatric nurse practitioner (PNP)-led class incorporating simulation on resident physician knowledge of the AAP and confidence in teaching families the AAP. The study setting was a 250 bed Midwest academic pediatric hospital. The 26 participants were second year residents completing a four-week pediatric pulmonary rotation. The class consisted of a brief didactic component regarding the AAP, simulation to teach a patient/parent actor the AAP based on PNP-developed scenarios, and debriefing of the experience. The average composite score on the pre- and post-simulation knowledge assessment showed improvement from 44.8% to 80.4% (p

Background Long-term adherence to prescription medications for the treatment of chronic disease remains low. While there are many contributors to suboptimal medication use, simple forgetfulness is widely believed to be central. Relatively simple devices may be a particularly cost-efficient and scalable way to promote adherence, however limited data exists about their ability to improve adherence in real-world settings. Methods/design The REMIND trial is a prospective, intent-to-treat randomized control trial to evaluate the impact on medication adherence of three simple, low-cost devices (Take-N-Slide™, the RxTimerCap™, and a standard pillbox). In March 2014, we enrolled 53,480 individuals 18 to 64 years old taking one to three medications to treat chronic disease whose prescription drug benefits were administered by CVS Caremark. The study's primary outcome is optimal adherence over the 12-month period after randomization. Using a randomization ratio of 1:2 between control and each intervention arm, the study has more than 80% power with an alpha of 5% to detect a 1% difference in the rate of optimal adherence between intervention and control groups and across intervention arms. Discussion The REMIND trial is the first randomized study to rigorously evaluate the impact of simple, low-cost reminder devices on medication adherence. The results will inform comparative cost effectiveness studies of reminder systems in improving medication adherence and clinical outcomes.