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RationaleLittle is known on the use of noninvasive ventilation (NIPPV) in pediatric hematopoietic cell transplant (HCT) patients.ObjectiveWe sought to describe the landscape of NIPPV use and to identify risk factors for failure to inform future investigation or quality improvement.MethodsThis is a multicenter, retrospective observational cohort of 153 consecutive children post-HCT requiring NIPPV from 2010-2016.Results97 (63%) failed NIPPV. Factors associated with failure on univariate analysis included: longer oxygen use prior to NIPPV (p=0.04), vasoactive agent use (p40 at 4 hours [aOR=6.3 9(95% CI: 2.4, 16.4), p

Moral distress is a well-documented phenomenon for health care providers (HCPs). Exploring HCPs' perceptions of participation in moral distress interventions using qualitative and quantitative methods enhances understanding of intervention effectiveness. The purpose of this study was to measure and describe the impact of a two-phased intervention on participants' moral distress. Using a cross-over design, the project aimed to determine if the intervention would decrease moral distress, enhance moral agency, and improve perceptions about the work environment. We used quantitative instruments and explored participants' perceptions of the intervention using semi-structured interviews. Participants were from inpatient settings, within three major hospitals of a large, urban healthcare system in the Midwest, United States. Participants included nurses (80.6%) and other clinical care providers. Using generalized linear mixed modeling we assessed the change in each of the outcome variables over time controlling for groups. Interviews were audiotaped and professionally transcribed. The written narratives were coded into themes. The change in scores on study instruments trended in the desired direction however did not meet statistical significance. Qualitative interviews revealed that intervention effectiveness was derived from a combination of learning benefits, psychological benefits, and building community that promoted moral agency. Findings demonstrate a clear link between moral distress and moral agency and suggest that Facilitated Ethics Conversations can enhance the work environment. Findings provide insight for developing evidenced-based approaches to address moral distress of hospital nurses. [ABSTRACT FROM AUTHOR]

BackgroundIn 2014, Joint Commission recommended palliative care (PC) engagement in ventricular assist device (VAD) implantation as destination therapy. Limited information is available on established PC protocols in the mechanical circulatory support (MCS) population.MeasuresThe goals of our PC consultation were to document advance care planning (ACP) discussions and designate a surrogate decision maker (SDM) before MCS implantation. A retrospective analysis compared the frequency of PC consults, ACP discussion, and SDM before and after protocol implementation.InterventionA protocol was developed to conduct interdisciplinary PC consultations for the MCS population.OutcomesThe percentage of PC consults placed before MCS implantation increased from 11 (17.2%) before protocol to 56 (96.6%) after protocol (P

Humans living at high-altitude (HA) have adapted to this environment by increasing pulmonary vascular and alveolar growth. RNA sequencing data from a novel murine model that mimics this phenotypical response to HA suggested estrogen signaling via estrogen receptor alpha (ERα) may be involved in this adaptation. We hypothesized ERα was a key mediator in the cardiopulmonary adaptation to chronic hypoxia and sought to delineate the mechanistic role ERα contributes to this process by exposing novel loss-of-function ERα mutant (ERαMut) rats to simulated HA. ERα mutant or wild-type (wt) rats were exposed to normoxia or hypoxia starting at conception and continued postnatally until 6 wk of age. Both wt and ERαMut animals born and raised in hypoxia exhibited lower body mass and higher hematocrits, total alveolar volumes (Va), diffusion capacities of carbon monoxide (DLCO), pulmonary arteriole (PA) wall thickness, and Fulton indices than normoxia animals. Right ventricle adaptation was maintained in the setting of hypoxia. Although no major physiologic differences were seen between wt and ERαMut animals at either exposure, ERαMut animals exhibited smaller mean linear intercepts (MLI) and increased PA total and lumen areas. Hypoxia exposure or ERα loss-of-function did not affect lung mRNA abundance of vascular endothelial growth factor, angiopoietin 2, or apelin. Sexual dimorphisms were noted in PA wall thickness and PA lumen area in ERαMut rats. In summary, in room air-exposed rats and rats with peri- and postnatal hypoxia exposure, ERα loss-of-function was associated with decreased alveolar size (primarily driven by hypoxic animals) and increased PA remodeling. NEW & NOTEWORTHY By exposing novel loss-of-function estrogen receptor alpha (Erα) mutant rats to a novel model of human high-altitude exposure, we demonstrate that ERα has subtle but inconsistent effects on endpoints relevant to cardiopulmonary adaptation to chronic hypoxia. Given that we observed some histologic, sex, and genotype differences, further research into cell-specific effects of ERα during hypoxia-induced cardiopulmonary adaptation is warranted. [ABSTRACT FROM AUTHOR]

Objective Bronchopulmonary dysplasia (BPD) is a major cause of morbidity in neonates and can be associated with long hospitalization and high health care utilization. This extremely stressful situation can be difficult for many families and caregivers. The high-risk situation combined with increased medical complexity can result in involvement of Department of Child Services (DCS) and even foster care placement. This study seeks to define risk factors for DCS involvement and foster care placement in children with BPD. Study Design A retrospective study of children born at less than 32 weeks of gestation born between 2010 and 2016, on oxygen at 28 days of life and discharged home from a tertiary care center. Results A total of 246 patients were identified. DCS was involved in 49 patients with 13 requiring foster care placement. The most common correlated risk factors that were identified for DCS involvement were maternal THC (tetrahydrocannabinol) positivity, hospital policy violations, maternal mental health diagnosis, and home insecurity. Home insecurity (p < 0.005) and amphetamine use (p < 0.005) were associated with foster care placement. Conclusion There are numerous risk factors for both DCS and foster care placement. The identification of these risk factors is important to help establish services to help families and identify potential biases to avoid. Key Points There were both substance-related and non-substance-related risk factors for DCS involvement. Home insecurity and maternal amphetamine use were risk factors associated with foster care placement. This study fills the knowledge gap of risk factors for DCS and foster care placement in BPD. [ABSTRACT FROM AUTHOR]

Background & Aims: Patients with acute liver failure (ALF) awaiting liver transplantation (LT) may develop multiorgan failure, but organ failure does not impact waitlist prioritization. The aim of this study was to examine the impact of organ failure on waitlist mortality risk and post LT outcomes in patients with ALF. Methods: We studied adults waitlisted for ALF in the United Network for Organ Sharing (UNOS) database (2002–2019). Organ failures were defined using a previously described Chronic Liver Failure modified sequential organ failure score assessment adapted to UNOS data. Regression analyses of the primary endpoints, 30‐day waitlist mortality (Competing risk), and post‐LT mortality (Cox‐proportional hazards), were performed. Latent class analysis (LCA) was used to determine the organ failures most closely associated with 30‐day waitlist mortality. Results: About 3212 adults with ALF were waitlisted, for hepatotoxicity (41%), viral (12%) and unspecified (36%) etiologies. The median number of organ failures was three (interquartile range 1–3). Having ≥3 organ failures (vs. ≤2) was associated with a sub hazard ratio (HR) of 2.7 (95%CI 2.2–3.4)) and a HR of 1.5 (95%CI 1.1–2.5)) for waitlist and post‐LT mortality, respectively. LCA identified neurologic and respiratory failure as most impactful on 30‐day waitlist mortality. The odds ratios for both organ failures (vs. neither) were higher for mortality 4.5 (95% CI 3.4–5.9) and lower for delisting for spontaneous survival.5 (95%CI.4–.7) and LT.6 (95%CI.5–.7). Conclusion: Cumulative organ failure, especially neurologic and respiratory failure, significantly impacts waitlist and post‐LT mortality in patients with ALF and may inform risk‐prioritized allocation of organs. [ABSTRACT FROM AUTHOR]