Resuscitative endovascular balloon occlusion of the aorta (REBOA) has reemerged as a treatment for noncompressible torso hemorrhage. This article discusses indications and contraindications for REBOA, describes the procedure, and reviews nursing considerations for patients undergoing REBOA.OBJECTIVES To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams. DESIGN Quasi-experimental; three pairs of control/intervention months June/July; August/October; November/December. SETTING Single-center, urban, quaternary academic children's hospital with three-member rapid response team critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU. SUBJECTS 1) Patients evaluated by rapid response team, 2) rapid response team members. INTERVENTIONS Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU. MEASUREMENTS AND MAIN RESULTS As a marker of efficiency, the primary provider outcome was time the rapid response team spensors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.OBJECTIVES Describe pediatric palliative care consult in children with heart disease; retrospectively apply Center to Advance Palliative Care criteria for pediatric palliative care consults; determine the impact of pediatric palliative care on end of life. DESIGN A retrospective single-center study. SETTING A 16-bed cardiac ICU in a university-affiliated tertiary care children's hospital. PATIENTS Children (0-21 yr old) with heart disease admitted to the cardiac ICU from January 2014 to June 2017. MEASUREMENTS AND MAIN RESULTS Over 1,000 patients (n = 1, 389) were admitted to the cardiac ICU with 112 (8%) receiving a pediatric palliative care consultation. Patients who received a consult were different from those who did not. Patients who received pediatric palliative care were younger at first hospital admission (median 63 vs 239 d; p = 0.003), had a higher median number of complex chronic conditions at the end of first hospitalization (3 vs 1; p less then 0.001), longer cumulative length of stay in the cardiac ICU (11 vs 2 d; p less then 0.001) and hospital (60 vs 7 d; p less then 0.001), and higher mortality rates (38% vs 3%; p less then 0.001). When comparing location and modes of death, patients who received pediatric palliative care were more likely to die at home (24% vs 2%; p = 0.02) and had more comfort care at the end of life (36% vs 2%; p = 0.002) compared to those who did not. The Center to Advance Palliative Care guidelines identified 158 patients who were eligible for pediatric palliative care consultation; however, only 30 patients (19%) in our sample received a consult. CONCLUSIONS Pediatric palliative care consult rarely occurred in the cardiac ICU. Patients who received a consult were medically complex and experienced high mortality. Comfort care at the end of life and death at home was more common when pediatric palliative care was consulted. Missed referrals were apparent when Center to Advance Palliative Care criteria were retrospectively applied.Assessment of vitamin and trace element status (VTE) is important in the clinical management of the sick child. In this position paper we present the various assessment methods available to the clinical practitioner, and critically discuss pitfalls with interpretation of their results.There are four main approaches to assess the VTE body status of an individual patient including clinical examination, dietary assessment and measurement of direct and indirect biomarkers of VTE in biological samples. Clinical signs of VTE deficiencies usually present only when body stores are substantially depleted and are often difficult to detect or differentiate from other non-nutrient related causes. In isolation, dietary assessment of micronutrients can be inaccurate and imprecise, in disease and in individual patient assessment, but may be useful to complement findings from other VTE assessment methods. Use of biomarkers is the most common approach to assess VTE status in routine practice, but in the presence of systemic inflammatory response and in the absence of appropriate paediatric reference intervals, interpretation of biomarker results might be challenging and potentially mislead clinical practice.The use of a multimodal approach, including clinical examination, dietary assessment and laboratory biomarkers is proposed as the optimal way to ascertain the VTE status of individual patients. In the presence of acute inflammatory conditions, VTE measurements in plasma should be replaced by biomarkers not affected by systemic inflammatory response or delayed until inflammatory state is resolved.Biological agents have revolutionized inflammatory bowel disease treatment but primary non-response and secondary loss-of-response are common with resulting adverse outcomes. Clinical trials demonstrated an association between serum drug concentrations, as well as the presence of antidrug antibodies, and loss-of-response. selleck chemicals Therapeutic drug monitoring (TDM), defined as the evaluation of drug concentrations and antidrug antibodies, is appearing as a strategy to optimize treatment and take full advantage from these drugs. TDM appears to be a promising tool in clinical practice, especially in pediatric patients, who have pronounced fluctuations in the pharmacokinetics of the drugs.The authors present a literature review about anti-tumor necrosis factor therapy optimization based on personalized treatment strategies according to therapeutic drug monitoring and possible strategies to recapture loss of response, including an algorithm for practical management.BACKGROUND Biliary atresia's (BA) response to surgical Kasai portoenterostomy (KP) is uneven and dependent upon bile flow; 50% of infants require a liver transplant by 24 months. We hypothesized that the microbiome may identify and associate with outcomes in BA. METHODS Stool samples were collected from infants with cholestasis (n = 15), 8 of which with BA were followed longitudinally.16S sequencing was performed on all samples (n = 45). Whole Genome Sequencing (WGS) was performed on BA pre-KP samples (n = 8). Infants with BA, other forms of cholestasis, BA infants with very good bile flow (VGBF) and not (nVGBF), (VGBF dichotomized by TSBA less then 40 μmol/L by 6 months) were compared. RESULTS Of the 8 infants with BA, 4 infants had VGBF. Microbial richness was inversely proportional to degree of cholestasis (p = 0.046). Increased Bifidobacterium abundance associated with VGBF (p = 0.03) and decreased cholestasis (p  less then  0.01) at 1 month post-KP. Pre-KP, community structure differed in infants with BA vs other cholestasis.