Objective In the Fluid and Catheter Treatment Trial (FACTT)(NCT00281268), adults with acute lung injury (ALI) randomized to a conservative versus liberal fluid management protocol had increased days alive and free of mechanical ventilator support (ventilator-free days). Recruiting sufficient children with ALI into a pediatric trial is challenging. A Bayesian statistical approach relies on the adult trial for the a priori effect estimate, requiring fewer patients. Preparing for a Bayesian pediatric trial mirroring FACTT, we aimed to: a.)Identify an inverse association between fluid balance and VFDs; and b.)Determine if fluid balance over time is more similar to adults in the FACTT liberal or conservative arms. Design Multi-centered retrospective cohort study. Setting Five pediatric intensive care units. Patients Mechanically ventilated children (age ≥1 month to <18 years) with ALI admitted 2007–2010. Interventions None. Measurements and Main Results Fluid intake, output and net fluid balance were collected days 1–7 in 168 children with ALI (median age 3 years, median PaO2/FiO2 138) and weight-adjusted (ml/kg). Using multivariable linear regression to adjust for age, gender, race, admission day illness severity, PaO2/FiO2 and vasopressor use, increasing cumulative fluid balance (ml/kg) at day 3 was associated with fewer VFDs (p=0.02). Adjusted for weight, daily fluid balance on days 1–3 and cumulative fluid balance on days 1–7 were higher in these children compared to adults in the FACTT conservative arm (p<0.001, each day) and was similar to adults in the liberal arm. Conclusions Increasing fluid balance at day three in children with ALI at these centers is independently associated with fewer VFDs. Our findings and the similarity of fluid balance patterns in our cohort to adults in the FACTT liberal arm demonstrate the need to determine whether a conservative fluid management strategy improves clinical outcomes in children with ALI and support a Bayesian trial mirroring the FACTT trial.

We report a middle-aged woman with a novel transthyretin (TTR) variant, Leu12Pro. She had extensive amyloid deposition in the leptomeninges and liver as well as the involvement of the heart and peripheral nervous system which characterizes familial amyloid polyneuropathy caused by variant TTR. Clinical features attributed to her leptomeningeal amyloid included radiculopathy, central hypoventilation, recurrent subarachnoid haemorrhage, depression, seizures and periods of decreased consciousness. MRI showed a marked enhancement throughout her meninges and ependyma, and TTR amyloid deposition was confirmed by meningeal biopsy. The simultaneous presence of extensive visceral amyloid and clinically significant deposits affecting both the peripheral and central nervous system extends the spectrum of amyloid-related disease associated with TTR mutations. The unusual association of severe peripheral neuropathy with symptoms of leptomeningeal amyloid indicates that leptomeningeal amyloidosis should be considered part of the syndrome of TTR-related familial amyloid polyneuropathy.

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Some agreement in goals for parent participation in morning rounds exists, although there are opportunities to calibrate expectations for both parents and health care providers. Solutions may involve a protocol for orienting parents to morning rounds, focusing on improving communication with parents outside of morning rounds, and the preservation of a forum for providers to have private discussions as a team.

This consensus from a group of leaders in medical education is a first step toward the implementation of more developmentally-appropriate SaT competencies.