No abstract

SUMMARYObjective: There is scant evidence to guide the management of infantile spasms after successful response to initial therapies. There is significant risk of relapse, largely because effective pharmacologic treatments cannot be continued long term because of concern for significant adverse events. Zonisamide (ZNS) and topiramate (TPM) are commonly used to prevent relapse, and the purpose of this study was to specifically evaluate the efficacy of ZNS and TPM as agents for secondary prevention of infantile spasms. Methods: Patients with video-electroencephalography (EEG) confirmed resolution of infantile spasms were retrospectively identified. Relevant clinical data were systematically collected, including lead time from onset of spasms to successful treatment response, etiology of infantile spasms, number of treatment failures prior to response, timing of relapse, and detailed exposure data for ZNS and TPM. Results: We identified 106 patients with response to hormonal therapy (n = 58), vigabatrin (n = 25), or surgery (n = 23). To prevent relapse of infantile spasms, 37 patients received ZNS, 34 received TPM, 3 received both ZNS and TPM, and 38 patients received neither ZNS nor TPM. There were 44 relapses, occurring a median of 6.9 (3.2-10.8) months after initial response. Time to relapse was not affected by treatment with ZNS or TPM. Relapse was less likely among patients who were older (hazard ratio 0.97 [per month], p = 0.036) and those who responded to surgical resection (hazard ratio = 0.28, p = 0.017). Of note, we identified a relatively refractory cohort with multiple treatment failures and long lead time to initial response. Significance: In this refractory cohort, neither ZNS nor TPM was successful in preventing relapse of infantile spasms, despite relatively high dosages. At this time, aside from surgical resection in eligible candidates, there is no known treatment that is efficacious in the prevention of relapse of infantile spasms.

Background As hospitals shift away from pagers and towards secure text messaging systems (STMS), limited research exists on the drawbacks of such systems. Preliminary data show that introduction of STMS can lead to a dramatic increase in interruptions, which may contribute to medical errors. Objective This study aimed to investigate residents' and nurses' experiences with STMS at a quaternary care children's hospital. Design This was a qualitative study with focus groups. Setting and Participants Participants were pediatric residents and nurses at Lucile Packard Children's Hospital. Intervention Focus groups were audio recorded, transcribed verbatim, and coded by 2 independent coders. Codes were discussed until consensus was reached. Main Outcome and Measures Data was analyzed through a thematic, descriptive content analysis approach. Themes were developed alongside a framework of teamwork, patient safety, and clinician well‐being. Results Three resident focus groups (n = 14) and three nurse focus groups (n = 21) were held. Six themes were identified: (1) STMS can facilitate teamwork through multiple communication modalities and technological features. (2) STMS can negatively impact teamwork by decreasing face‐to‐face communication and frontline decision‐making. (3) STMS can promote patient safety through closed‐loop communication and ready access to team members. (4) STMS can negatively impact patient safety through alarm fatigue, interruptions, and miscommunication. (5) STMS can positively impact clinician well‐being through satisfaction and relationship building. (6) STMS can negatively impact clinician well‐being through increased stress related to communication volume. Conclusion Use of STMS in the hospital setting has many advantages as well as drawbacks. With appropriate guidelines and training designed to mitigate the drawbacks, STMS have the potential to be valuable means of communication for healthcare team members.