The use of a clinical pathway for sickle cell VOC in the PED can improve important aspects of pain management and merits further investigation and implementation.

This pilot study was undertaken to evaluate the hypotheses that there are differences in pediatric pain management (PPM) knowledge across resident specialties, that questions in the form of multiple-choice items could detect such differences, and that resident knowledge of analgesic-related adverse drug events (ADEs) would be greater than knowledge of PPM. Questions were based on two general categories of knowledge within acute pain management in hospitalized children: pediatric pain assessment and treatment, and identification of analgesic-related ADEs. As part of the pilot nature of this study, a convenience sample of 60 residents completed a 10-item PPM knowledge assessment prior to a PPM lecture. Twenty-six were pediatric residents (43%), 19 were orthopedic residents (32%), and 15 were anesthesiology residents (25%). All items had content validity. When controlling for resident year, performance by resident specialty was significantly different between anesthesia and orthopedics (P=0.006) and between anesthesia and pediatrics (P<0.001). Resident knowledge of analgesic-related ADEs was not greater than knowledge of PPM. The most difficult topics were opioid equianalgesia, assessment of the cognitively impaired child, and maximal acetaminophen doses. Repeated administration of the PPM knowledge assessment at multiple institutions will allow further evaluation of our initial findings, and with directed educational interventions, provide opportunity for measurement of improvement.

Phenomenologic analysis of initial consults provided during the first year of a new Pediatric Advanced Care Team (PACT) program provides essential understanding of the experience and inform program direction and future clinical research. Parents bring to the consult a desire to remain experts in their children's lives yet experience vulnerability as they seek assistance in making critical decisions often under conditions of disquieting uncertainty. Dynamic communication efforts involving the referring providers, PACT team members, and family are a key influence in facilitating consults' stated goals and in establishing the integrated palliative paradigm in a tertiary care environment. Validation was provided for a new research infrastructure that will function concurrently with the PACT clinical program in this rapidly evolving field.

Forty-two patients (28 men and 14 women) with acute myocardial infarction (35 Q, seven non-Q wave) were injected with 2.0 mCi indium 111-labeled antimyosin (AM) monoclonal antibody (`111n AM) within 48 hours of the onset of chest pain. Forty-eight hours later (72-96 hours after onset of chest pain), patients were injected with 2.2 mCi thallium 201, and two sets of single-photon emission computed tomography (SPECT) images were obtained simultaneously using dual energy windows set for the 247 keV indium photopeak and the 70 keV thallium peak. Seventeen patients had repeat scans at 4 hours. "'in AM uptake and 201T1 defects were localized to one or more of 24 coronal and sagittal segments. Scans with only 201T1 defects and corresponding "'In AM uptake were classified as matches; scans with unmatched '0TI defects in addition to matching regions corresponding to electrocardiographic infarct location were classified as mismatches; and scans with 20MT1 and`'In AM uptake in the same segments were classified as overlap. Scan patterns were correlated with clinical evidence for residual ischemia occurring within 6 weeks of infarct and including infarct extension, recurrent angina, and positive predischarge low-level or 6-week symptom-limited stress tests and with coronary anatomy. Fourteen patients had only matching patterns (group 1), 23 had mismatches (group 2), and five had 201T1-1'In overlap as the predominant pattern. None of the patients in group 1 had previous myocardial infarction; in each, the matched area corresponded to the Q wave location on electrocardiogram, and none had further in-hospital ischemic events or positive stress tests. In contrast, nine patients in group 2 had previous myocardial infarction, and 16 of the 23 went on to have further evidence of ischemia. There was a significant correlation between further ischemic events and mismatching 201T1-111n AM activity (p<0.01). In conclusion, these results suggest that simultaneous SPECT imaging with 201T1 and`'In AM, performed 72-96 hours postinfarct, might be useful for identifying patients with benign in-hospital courses and those with myocardium at further ischemic risk. (Circulation 1990;81:37-45) E arly hospital discharge for some patients after acute myocardial infarction has been proposed.' It would be useful to identify patients who are likely to have benign postinfarction in-hospital courses early after the acute event. Likewise, identifying patients with further myocardium at ischemic risk early in their hospital course would help direct their physicians toward early catheterization and revascularization by either percutaneous transluminal coronary artery angioplasty (PTCA) or coronary bypass grafting. A decision-making point is atFrom the

Background: Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. Aim: The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. Design: This is a cross-sectional survey of nationally representative US nursing homes. Setting/participants: Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. Results: Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. Conclusion: The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.

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To evaluate the effect of infarct size on left ventricular volumes and geometric remodeling, 26 patients with a first acute Q wave myocardial infarction (anterior in 14, inferior in 12) had the infarct sized from single-photon emission computed tomographic (SPECT) imaging of indium-111 antimyosin. All patients underwent gated blood pool scintigraphy before hospital discharge for determination of ejection fraction and end-diastolic and end-systolic volume indexes. Infarct size was quantitated from indium-111 antimyosin uptake in coronal slices with use of a threshold technique for edge detection. Nineteen of 26 patients had additional simultaneous acquisitions of indium-111 and thallium-201 uptake and the infarct was expressed as a percent of the total left ventricle. Infarct size was larger (59 +/- 16 vs. 33 +/- 16 g), predischarge ejection fraction lower (35 +/- 5% vs. 60 +/- 9%) and end-systolic volume index higher (57 +/- 13 vs. 36 +/- 10 ml/m2) in the group with anterior infarction. Despite these differences, predischarge end-diastolic volume index was not significantly different between the group with anterior (88 +/- 17 ml/m2) versus inferior (89 +/- 14 ml/m2) infarction. There was a significant inverse correlation between percent infarct size and ejection fraction for patients with dual isotope imaging (r = -0.90) and a significant direct correlation between infarct size and end-systolic volume index (r = 0.79, p less than 0.01). Fourteen patients without subsequent myocardial infarction or coronary artery bypass grafting had a repeat gated blood pool study late (26 +/- 15 months) after infarction.(ABSTRACT TRUNCATED AT 250 WORDS)