bluuebunny/crossref_metadata_2025 huggingface dataset:
A Systematic Review and Meta-analysis of Unguided Electronic and Mobile Health Technologies for Chronic Pain—Is It Time to Start Prescribing Electronic Health Applications?
Authors: Moman Rajat N , Dvorkin Jodie , Pollard E Morgan , Wanderman Robalee , Murad M Hassan , Warner David O , Hooten W Michael
Published: June 2019

Objective

Electronic (eHealth) and mobile (mHealth) technologies may be a useful adjunct to clinicians treating patients with chronic pain. The primary aim of this study was to investigate the effects of eHealth and mHealth interventions that do not require clinician contact or feedback on pain-related outcomes recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) guidelines in adults with chronic pain.

Methods

We searched four databases and included English language randomized controlled trials of ambulatory adults with chronic pain from January, 1 2000, to January 31, 2018, with interventions that are independent of clinician contact or feedback. In the meta-analysis, outcomes were assessed at short- (three months or less), intermediate- (four to six months), and long-term (seven or more months) follow-up.

Results

Seventeen randomized controlled trials (N = 2,496) were included in the meta-analysis. Both eHealth and mHealth interventions had a significant effect on pain intensity at short- and intermediate-term follow-up. Similarly, a significant but small effect was observed for depression at short- and intermediate-term follow-up and self-efficacy at short-term follow-up. Finally, a significant effect was observed for pain catastrophizing at short-term follow-up.

Conclusions

eHealth and mHealth interventions had significant effects on multiple short- and intermediate-term outcome measures recommended in the IMMPACT guidelines. Given widespread availability and low cost to patients, clinicians treating patients with chronic pain could consider using eHealth and mHealth interventions as part of a multidisciplinary pain treatment strategy.
Usability of donor corneas harvested from the deceased having septicaemia or malignancy
Authors: Singh T , Arya S K , Handa U , Chander J
Published: June 2019

Context

There is a wide gap between supply and demand in relation to healthy corneal grafts. Specific contraindications like infection and malignancy lead to non-usage of many grafts, despite the fact that deeming graft unhealthyness for these two contraindications is debatable.

Aims

This study was conceptualized to assess if corneas donated from the deceased with septicaemia or malignancy can be deemed fit for implantation.

Settings and design

Retrospective histopathological and microbiological analysis of cadaveric donor corneas.

Methods

A total of 76 donor corneas from 38 patients rejected for corneal transplantation in view of patient having septicaemia or malignancy were analysed for pathological and microbiological workup, to look for dissemination of disease within corneal tissue. Pathology workup included gross and microscopic histopathological evaluation of tissue. Microbiology workup included Grams stain and KOH with calcofluor mount, culture in blood agar, chocolate agar, Sabourauds dextrose agar and Mc Conkeys broth.

Results

A total of 46 donor corneas of 23 septicaemia patients when evaluated showed presence of culture positive infection in 18 patients (78.2%). Histopathological examination done for 30 donor corneas from 15 cancer patients did not reveal presence of tumour cells in the specimen. Corneas of two of cancer patients having septicaemia revealed growth on cultures.

Conclusions

Corneal tissues harvested from septicaemia donors showed significantly higher incidence of corneal contamination, confirming their unsuitability for usage. However, there was no incidence of tumour transmission in corneal tissues of the patients with malignancies, suggesting that they can be considered for ophthalmic purpose.
Bariatric surgery and the incidence of rheumatoid arthritis – a Swedish Obese Subjects study
Authors: Maglio Cristina , Zhang Yuan , Peltonen Markku , Andersson-Assarsson Johanna , Svensson Per-Arne , Herder Christian , Rudin Anna , Carlsson Lena
Published: June 2019

Objective

The aim of this study was to determine the effect of bariatric surgery on the incidence of RA in participants of the Swedish Obese Subjects (SOS) study.

Methods

The SOS is a longitudinal study aiming to assess the effect of bariatric surgery on mortality and obesity-related diseases. This report includes 2002 subjects with obesity who underwent bariatric surgery and 2034 matched controls; none of them had RA at baseline. Cases of incident RA were identified through the Swedish National Patient Register by searching for International Classification of Diseases codes. Both intention-to-treat analyses and per-protocol analyses are reported. In the per-protocol analysis, participants from the control group who underwent bariatric surgery later on during follow-up were censored at the time of surgery.

Results

During follow-up, 92 study participants developed RA. The median follow-up was 21 years (range 0–29). Bariatric surgery was neither associated with the incidence of RA in the intention-to-treat analysis [hazard ratio (HR) 0.92 (95% CI 0.59, 1.46), P = 0.74], nor in the per-protocol analysis [HR 0.86 (95% CI 0.54, 1.38), P = 0.53]. Weight change at the 2 year follow-up, expressed as the change in BMI compared with baseline, did not associate with the development of RA. Higher serum CRP levels and smoking associated with the future development of RA independent of other factors.

Conclusions

We did not detect any association between bariatric surgery and the incidence of RA in subjects affected by obesity followed up for up to 29 years.

ClinicalTrials.gov

(http://clinicaltrials.gov): NCT01479452.
Exposure to an Environmentally Relevant Phthalate Mixture During Prostate Development Induces MicroRNA Upregulation and Transcriptome Modulation in Rats
Authors: Scarano Wellerson R , Bedrat Amina , Alonso-Costa Luiz G , Aquino Ariana M , Fantinatti Bruno E A , Justulin Luis A , Barbisan Luis F , Freire Paula P , Flaws Jodi A , Lemos Bernardo
Published: June 2019

Environmental exposure to phthalates during intrauterine development might increase susceptibility to neoplasms in reproductive organs such as the prostate. Although studies have suggested an increase in prostatic lesions in adult animals submitted to perinatal exposure to phthalates, the molecular pathways underlying these alterations remain unclear. Genome-wide levels of mRNAs and miRNAs were monitored with RNA-seq to determine if perinatal exposure to a phthalate mixture in pregnant rats is capable of modifying gene expression during prostate development of the filial generation. The mixture contains diethyl-phthalate, di-(2-ethylhexyl)-phthalate, dibutyl-phthalate, di-isononyl-phthalate, di-isobutyl-phthalate, and benzylbutyl-phthalate. Pregnant females were divided into 4 groups and orally dosed daily from GD10 to PND21 with corn oil (Control: C) or the phthalate mixture at 3 doses (20 μg/kg/day: T1; 200 μg/kg/day: T2; 200 mg/kg/day: T3). The phthalate mixture decreased anogenital distance, prostate weight, and decreased testosterone level at the lowest exposure dose at PND22. The mixture also increased inflammatory foci and focal hyperplasia incidence at PND120. miR-184 was upregulated in all treated groups in relation to control and miR-141-3p was only upregulated at the lowest dose. In addition, 120 genes were deregulated at the lowest dose with several of these genes related to developmental, differentiation, and oncogenesis. The data indicate that phthalate exposure at lower doses can cause greater gene expression modulation as well as other downstream phenotypes than exposure at higher doses. A significant fraction of the downregulated genes were predicted to be targets of miR-141-3p and miR-184, both of which were induced at the lower exposure doses.
Development and Application of Real-Time and Conventional SSR-PCR Assays for Rapid and Sensitive Detection of Didymella pisi Associated with Ascochyta Blight of Dry Pea
Authors: Owati Ayodeji , Agindotan Bright , Burrows Mary
Published: June 2019

Didymella pisi is the primary causal pathogen of Ascochyta blight (AB) of dry pea in Montana. Diagnosis of AB is challenging because there are six different species that cause AB worldwide and that can co-occur. Additionally, agar plate identification of D. pisi is challenging due to its slow growth rate. Currently, there are no PCR-based assays developed for specific detection of D. pisi or any fungal pathogen in the AB complex of dry pea. In this study, we evaluated simple sequence repeat (SSR) primer pairs for their specificity and sensitivity in real-time and conventional SSR-PCR both in vitro and in planta. The specificity of the assay was determined by testing DNA of 10 dry pea varieties, fungal species in the AB complex, and fungal species associated with dry pea. To avoid false-negative results, plant and fungal DNA markers were included as controls in a conventional multiplex SSR-PCR, to amplify any plant or fungal DNA in the absence of the D. pisi SSR target. SYBR Green SSR-quantitative PCR (qPCR) detection was conducted using the same primer pairs but in a uniplex format. D. pisi was specifically amplified, whereas other fungi and host DNA were not. Also, sensitivity experiments showed that the detection limit was 0.01 ng of DNA of D. pisi for both assays and 100 conidia in SSR-qPCR. These assays are valuable diagnostic tools for the detection of D. pisi.
Evaluating the impact of a global surgery conference on student perceptions: a survey study
Authors: Young Jason , Turk Marvee , Fallah Parisa N. , Afshar Salim
Published: June 2019

Background:

Global surgery is an under-represented component of formal medical education. Consequently, many students and trainees have turned to complementary learning opportunities, like academic conferences, to gain experience in the field. The impact of such conferences on student attitudes, however, has not yet been described. Our objective is thus to evaluate the impact of a student-oriented global surgery conference on participants’ perceptions of global surgery.

Methods:

A survey study was performed. Preconference and postconference surveys were administered to participants of a 1-day, student-oriented global surgery conference in Boston, MA.

Results:

Of conference participants, 116 completed a preconference survey, and 70 completed a postconference survey. Of the latter, 58 participants completed a postconference survey that could be matched to their preconference survey results. The majority of conference participants had no or limited (<1 y) prior experience in global health or global surgery (26% and 58%, respectively). After participation in the conference, respondents indicated a significantly greater confidence in their understanding of global surgery as a career (P<0.00001). There were no significant changes in participants’ beliefs about or interest in global surgery subfields after correcting for multiple hypothesis testing.

Conclusions:

Student-oriented global surgery conferences can increase participant confidence in their understanding of global surgery as a career. Further pedagogical inquiry is needed to build a more integrated educational experience for students and trainees interested in gaining exposure to the field.
Impact of a Longitudinal Quality Improvement and Patient Safety Curriculum on Pediatric Residents
Authors: Vachani Joyee G. , Mothner Brent , Lye Cara , Savage Charmaine , Camp Elizabeth , Moyer Virginia
Published: June 2019

Introduction:

The effectiveness of longitudinal quality/safety resident curricula is uncertain. We developed and tested our longitudinal quality improvement (QI) and patient safety (PS) curriculum (QIPSC) to improve resident competence in QI/PS knowledge, skills, and attitudes.

Methods:

Using core features of adult education theory and QI/PS methodology, we developed QIPSC that includes self-paced online modules, an interactive conference series, and mentored projects. Curriculum evaluation included knowledge and attitude assessments at 3 points in time (pre- and posttest in year 1 and end of curriculum [EOC] survey in year 3 upon completion of all curricular elements) and skill assessment at the EOC.

Results:

Of 57 eligible residents in cohort 1, variable numbers of residents completed knowledge (n = 42, 20, and 31) and attitude (n = 11, 13, and 37) assessments in 3 points in time; 37 residents completed the EOC skills assessment. For knowledge assessments, there were significant differences between pre- and posttest and pretest and EOC scores, however, not between the posttest and EOC scores. In the EOC self-assessment, residents’ attitudes and skills improved for all areas evaluated. Additional outcomes from project work included dissemination of QI projects to hospital-wide quality/safety initiatives and in peer-reviewed national conferences.

Conclusions:

Successful implementation of a QIPSC must be responsive to a number of learners, faculties, and institutional needs and integrate adult learning theory and QI/PS methodology. QIPSC is an initial effort to address this need; follow-up results from subsequent learner cohorts will be necessary to measure the true impact of this curriculum: behavior change and practice improvements.
Potential Acetaminophen and Opioid Overdoses in Young Children Prescribed Combination Acetaminophen/Opioid Preparations
Authors: Basco William T. , Garner Sandra S. , Ebeling Myla , Hulsey Thomas C. , Simpson Kit
Published: June 2019

Introduction:

Combination preparations of acetaminophen/opioid are the most common opioid form prescribed to children. We tested the hypothesis that dispensed prescriptions of acetaminophen/opioid preparations more appropriately match acetaminophen dosing parameters than opioid dosing parameters. We also hypothesized that the frequency of potential overdose was inversely related to subject age.

Methods:

Using 2011 to 2012 South Carolina outpatient Medicaid data, the authors identified acetaminophen/opioid preparations dispensed to children 0 to 36 months. Utilizing Centers for Disease Control and Prevention (CDC) data to impute subject weights as the 97th percentile for age and gender, the authors used imputed weights to calculate the maximum recommended daily dose (expected dose) of each component. We calculated the dose delivered per day (observed dose) based on drug concentration, volume dispensed, and days’ supply and then calculated the frequency of overdose (observed dose/expected dose, >1.10) by each component, comparing overdose frequency of acetaminophen to the overdose frequency of opioid using a risk ratio. Logistic regression evaluated differences in potential overdose by age, controlling for race/ethnicity and gender.

Results:

Among 2,653 dispensed prescriptions of study drugs to 2,308 children 0 to 36 months old, the frequency of potential overdose was 0.7% for acetaminophen and 1.6% for opioid (risk ratio, 2.28). Age less than 3 months was associated with a greater frequency of potential overdose of either acetaminophen or opioid, even after controlling for gender and race/ethnicity.

Conclusions:

Prescriptions of acetaminophen–opioid drugs dispensed to children 0 to 36 months old contained potential overdoses of opioid at greater than twice the frequency of acetaminophen and were more likely to occur in infants less than 3 months old.
A Quality Improvement Initiative to Standardize Use of Inhaled Nitric Oxide in the PICU
Authors: Karsies Todd J. , Evans Laura , Frost Randall , Ayad Onsy , McClead Richard
Published: June 2019

Background:

Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator used off-label to treat refractory hypoxemia in the pediatric intensive care unit (PICU). However, clinical practice varies widely, and there is limited evidence to support this expensive therapy. Our objective was to test whether implementation of a clinical guideline for iNO therapy would decrease practice variability, reduce ineffective iNO utilization, and control iNO-related costs.

Methods:

We used quality improvement (QI) methodology to standardize the use of iNO in a single quaternary care PICU (noncardiac). All PICU patients receiving iNO therapy between January 1, 2010, and December 31, 2013, were included. The QI intervention was the development and implementation of a clinical guideline for iNO initiation, continuation, and weaning. iNO use was monitored using statistical process control charts.

Results:

We derived baseline data from 30 preguideline patients (35 separate iNO courses) compared with 33 postguideline patients (36 separate iNO courses). Despite similar baseline characteristics, disease severity, and degree of hypoxemia, postguideline patients had a shorter median [interquartile range (IQR)] duration of iNO therapy than preguideline patients [76 (48–124) hours versus 162 (87–290) hours; P < 0.0001]. We have sustained the reduced iNO usage throughout the postguideline period. Postguideline patients also had improved provider documentation and a median iNO cost savings of $4,600.

Conclusions:

Implementation of iNO usage guidelines was associated with decreased iNO usage and cost of iNO therapy in the PICU.
Improving the Performance of Anthropometry Measurements in the Pediatric Intensive Care Unit
Authors: Srinivasan Vijay , Seiple Stephanie , Nagle Monica , Falk Shiela , Kubis Sherri , Lee Henry M. , Sisko Martha , Mascarenhas Maria , Irving Sharon Y.
Published: June 2019

Introduction:

Obtaining anthropometry measurements in critically ill children is challenging. Our objective was to improve the process of obtaining anthropometry measurements in the pediatric intensive care unit (PICU; even if previously obtained) using a dedicated PICU nutrition support team (NST).

Methods:

PICU staff were trained to perform anthropometry measurements through online education, skills training, and just-in-time bedside teaching by the PICU NST. Equipment was upgraded and standardized throughout the PICU along with implementation of preselected orders in the electronic medical record. Data were collected before and immediately after intervention and at monthly intervals from 12 to 36 months to test sustainability of practice change. PICU staff were surveyed on barriers to anthropometry measurements at 36 months after initial intervention.

Results:

Compared with baseline, the intervention resulted in more patients with orders for weight, stature, and head circumference (all P < 0.001) at PICU admission. Correspondingly, more patients had measurements of weight (P = 0.04), stature (P = 0.01), and head circumference (P = 0.009) at PICU admission. For long-stay patients (>7 days), compliance improved with measurements of serial weights (P = 0.002), stature (P < 0.001), and head circumference (P = 0.02). Between 12 and 36 months after the intervention, there was a noticeable trend to increases in weight measurements at PICU admission, and to a lesser extent, of stature and head circumference. Competing clinical priorities were a key barrier to anthropometry measurements.

Conclusions:

Performance of anthropometry measurements in the PICU can be improved by a dedicated PICU NST; however, sustaining these improvements is challenging due to competing clinical priorities.
Increasing Physical Exam Teaching on Family-Centered Rounds Utilizing a Web-Based Tool
Authors: Patel Aarti , Unaka Ndidi , Holland Deborah , Schuler Christine , Mangeot Colleen , Sucharew Heidi , Younts Angela , Maag Logan , Treasure Jennifer , Sobolewski Brad , Statile Angela
Published: June 2019

Introduction:

Millennial trainees prefer innovative, multimodal education on topics including the physical exam (PE). Attendings inconsistently meet these needs on family-centered rounds. To enhance PE teaching, a Web site (PEToolkit) was created, but its use was infrequent. We aimed to increase PEToolkit use from 2 to 5 page counts per week in 7 months.

Methods:

This quality improvement project took place at a large academic center in 1 Hospital Medicine team. Key drivers informed interventions, and an annotated run chart tracked progress. We tracked secondary measures, including changes in perception of teaching skill among attendings and resident-observed methods of PE teaching, through survey methodology.

Results:

Median page counts increased to 5 counts per week in 7 months. The most impactful interventions included training senior residents to teach with the PEToolkit Web site and team feedback on Web site usage midweek. Survey responses from 37 attendings showed that those with more exposure to PEToolkit had increased self-perceived skill of PE teaching (P = 0.02). Survey responses from 52 residents showed that those on the intervention team reported more use of video for PE teaching (P < 0.001) and higher frequency of PE teaching (P = 0.02), compared with those on the nonintervention team.

Conclusions:

We increased PEToolkit Web site use during family-centered rounds, thereby emphasizing the importance of PE teaching in this setting in an innovative way. Engagement of learners, frequent feedback, and coaching should be considered when incorporating technology in teaching.
Noncompliance to a Postoperative Algorithm Using Feeding Readiness Assessments Prolonged Length of Stay at a Pediatric Heart Institute
Authors: Ehrmann Daniel E. , Harendt Shaunda , Church Jessica , Stimmler Amy , Vichayavilas Piyagarnt , Batz Sanja , Rodgers Jennifer , DiMaria Michael , Barrett Cindy , Kaufman Jon
Published: June 2019

Introduction:

Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS.

Methods:

We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a “sentinel” FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm.

Results:

Sixty-nine patients were included. Forty-nine complied with the algorithm (71%), and 45 received GT (65.2%). Noncompliers had significantly longer LOS (34 versus 25 days; P = 0.01). Among GT recipients, noncompliers waited 6 additional days for a GT compared with compliers (P ≤ 0.001). Subjective decisions to extend oral feeding trials or await results of a swallow study were associated with algorithm noncompliance.

Conclusions:

This audit of compliance to a feeding algorithm after pediatric cardiac surgery highlighted variability of practice, including relying on subjective appraisals of feeding skills over objective FRAs. This variability was associated with increased LOS and can be hypothesis-generating for future quality improvement efforts.
WE CARE 4 KIDS: Use of a Rounding Tool in the Pediatric Intensive Care Unit
Authors: Ganesan Rani , Rajakumar Priya , Fogg Louis , Silvestri Jean , Kane Jason M.
Published: June 2019

Objective:

To implement a daily rounding tool in a pediatric intensive care unit (PICU) to improve the discussion performance of identified clinical elements. We hypothesized that a semi-structured rounding tool created by a multidisciplinary team would be successfully implemented and sustained in the PICU.

Patients and Methods:

A pre–post interventional study was conducted in a multidisciplinary medical-surgical PICU. Baseline data collection of undisclosed clinical elements was performed by covert observers, which resulted in the development of a comprehensive, nurse-driven rounding checklist. Frequencies of pre- and postintervention metrics were assessed after implementation, and sustainability was assessed at 5 years.

Results:

Six months after implementation, 70% (7/10) of checklist elements demonstrated significant improvement. Five years after implementation, 172 of a possible 222 (74%) checklists were collected. Eighty percentage (8/10) of the measures sustained discussion frequency after 5 years of use. Nursing presence significantly improved at year 5 compared with the preimplementation period. Nursing satisfaction surveys distributed at year 5 showed that the rounding tool was useful and nurses were confident in understanding care plans at the end of rounds. Ninety-eight percentage of checklists revealed discrete transcription of qualitative daily goals.

Conclusions:

A semi-structured rounding tool created by a multidisciplinary team was successfully implemented, and performance was sustained at 5 years. This initiative led to improved bedside nursing presence during patient care rounds.
Reducing Interdisciplinary Communication Failures Through Secure Text Messaging: A Quality Improvement Project
Authors: Hansen Jesse E. , Lazow Margot , Hagedorn Philip A.
Published: June 2019

Introduction:

Interdisciplinary communication failures contribute to medical mistakes and adverse events. At our institution, provider communication previously occurred through unidirectional pager systems. We utilized quality improvement methodology to (1) implement a secure text messaging system for providers on a pediatric ward and (2) evaluate its impact on communication failures. We aimed to reduce potential communication failures between providers by > 25% within 1 month.

Methods:

Implementation of secure text messaging occurred via Plan-Do-Study-Act cycles focused on education, feedback, and electronic health record interventions. We collected pager data before implementation and both pager and secure text messaging data after intervention. Potential communication failures were identified a priori through manual review of the messaging data to capture lack of closed-loop communication. A run chart was used to track daily potential communication failures and total communication volumes.

Results:

Before implementation of secure text messaging, the median daily potential communication failure rate was 5.5%. Usage of secure text messaging increased after implementation, representing 3.5 of 7.2 communications per patient-day. Paging communications decreased from 4.2 to 3.7 per patient-day. Potential communication failures decreased to a median daily rate of 2.2%, representing a 59% reduction in communication failures.

Conclusion:

Implementation of secure text messaging using quality improvement methods resulted in a significant reduction in potential communication failures between residents and nurses. Future interventions will be aimed at maintaining and augmenting providers’ use of secure text messaging to ensure the potential for communication failure remains low.
There’s an App for That; Improving Communication during Pediatric Cardiothoracic Surgery
Authors: Hodge Ashley B. , Joy Brian F. , Cox Virginia K. , Naguib Aymen N. , Tumin Dmitry , Galantowicz Mark E.
Published: June 2019

Introduction:

Waiting while a loved one is in surgery can be a very stressful time. Current processes for updating families vary from institution to institution. Providing timely and relevant updates, while important to the family, may strain a surgical team’s operational system. In our initial experience with the Electronic Access for Surgical Events (EASE) application (app), we tested the extent to which its implementation improved communication with patient families.

Methods:

We compared compliance data collected pre-EASE (December 2013 through September 2014) and post-EASE implementation (October 2014 until December 2015).

Results:

Although the pre-EASE compliance rate for bi-hourly updates was 46% (118/255) of cases, post-EASE implementation achieved a compliance rate of 97% (171/176). A 2-sample test of proportions confirmed a significant improvement in compliance after the introduction of EASE technology (P < 0.001). Analysis of the 177 noncompliant cases in the pre-EASE period indicated that noncompliance occurred most frequently at the end of the case (97/177, 55%) when the patient remained in the operating room > 2 hours after the last update to the family. We also observed noncompliance at the beginning of the case (46/177, 26%), when the patient arrived in the operating room > 2 hours before the time of the first update. Family satisfaction scores that rated their experience during surgery as “Very Good” improved from 80% pre-EASE implementation to 97% postimplementation. We sustained this improvement for 1 year.

Conclusions:

A mobile technology app (EASE) improved both frequency and compliance with surgical updates to families, which resulted in a statistically significant increase in family satisfaction scores.
Total Parenteral Nutrition Standardization and Electronic Ordering to Reduce Errors: a Quality Improvement Initiative
Authors: Crews Jacquelyn , Rueda-de-Leon Elena , Remus Denise , Sayles Russell , Mateus Jazmine , Shakeel Fauzia
Published: June 2019

Introduction:

Total parenteral nutrition (TPN) provides vital intravenous nutrition for patients who cannot tolerate enteral nutrition but is susceptible to medical errors due to its formulation, ordering, and administrative complexities. At Johns Hopkins All Children’s Hospital, 22% of TPN orders required clarification of errors and averaged 10 minutes per order for error correction by pharmacists. Quality improvement methodology improved patient safety by standardizing TPN formulations and incorporating TPN ordering processes into the electronic medical record.

Methods:

A multidisciplinary group of providers developed standardized TPN solutions for neonatal and pediatric patients. Inclusion, exclusion, and discontinuation criteria were defined. The primary outcome measure was reducing TPN ordering error rate, and secondary outcomes were improving TPN ordering and processing time along with reducing blood draws. Through multiple plan-do-study-act cycles, we standardized TPN solutions, incorporated them in the electronic medical record, monitored blood draws, and evaluated resource efficiency. Data were analyzed using chi-square tests of independence and t tests for 2 independent samples.

Results:

The TPN ordering error rate significantly decreased from baseline of 22% to 3.2% over the final quarter of the study period, χ2 (1, N = 2,467) = 89.13, P < 0.001. Order processing time fell from 10 to 5 minutes by project end. The average number of blood draws decreased significantly from 6.2 (SD = 3.12) blood draws to 4.3 (SD = 2.13) in the last quarter of the study, t (506) = 5.97, P < 0.001.

Conclusions:

Standardizing TPN and transitioning to electronic ordering effectively and significantly reduced ordering errors and processing time. It also substantially improved resource efficiency by reducing the number of blood draws.
Improving Reliability to a Care Goal Rounding Template in the Pediatric Intensive Care Unit
Authors: Efune Proshad N. , Morse Rustin B. , Sheehan Maeve , Malone Loren M. , Robertson Tammy S. , Darnell Cindy
Published: June 2019

Background:

Effective pediatric intensive care requires addressing many important aspects of care delivery during morning rounds, often achieved using a rounding checklist. Our objective was to develop a care goal rounding template and then double the reliability of discussion of rounding topics during morning rounds without the use of a checklist.

Methods:

The Institute for Healthcare Improvement Model for Improvement was used for this initiative. A care goal rounding template was established through discussions and consensus with pediatric intensive care unit (PICU) faculty. Rounds were audited in a blinded fashion over a 3-month period to obtain baseline data on rounding topic discussion. Three interventions were then trialed (plan, do, study, act cycles) over a 12-month period. Weekly reliability in rounding topic discussion was tracked.

Results:

Baseline reliability with discussion of rounding topics was 36%. The first intervention included the use of a standardized progress note in the electronic health record, which contained topics and served to prompt the discussion on rounds. The second intervention was implementation of laminated cards provided to PICU fellows highlighting the elements of the care goal rounding template. The third intervention addressed a standardized handoff sheet often used during rounds. Mean reliability for discussion of rounding topics improved to 52% shortly following the second intervention. Reliability was sustained more than 1 year later.

Conclusions:

Following the establishment of a PICU care goal rounding template and various interventions, the reliability in discussing important care goal elements on patient rounds improved.
Utilization of a Dual Surveillance Program to Reduce Surgical-site Infections
Authors: Song Xiaoyan , Oetgen Matthew E. , Magge Suresh N. , Berger John T. , Shah Rahul K.
Published: June 2019

Background:

Surveillance plays a pivotal role in the surgical-site infections (SSIs) prevention through identifying infections, monitoring changes in infection rates, and evaluating the effectiveness of intervention strategies.

Methods:

This retrospective study reviewed SSI surveillance systems implemented at the Children’s National Health System in 3 phases between 2007 and 2016 including all surgical procedures. The targeted surveillance was conducted in cardiovascular, spinal fusion, and ventricular shunt surgeries and required an infection preventionist (IP) to review all procedures, to identify SSIs that meet the CDC’s National Healthcare Safety Network definition. SSIs in the remaining surgical procedures were identified through the review of positive microbiology reports daily and followed by full chart review if the specimen type and/or patient location were suggestive of a surgical history. Timely feedback of SSI to stakeholders was the primary mode of intervention, with additional interventions implemented for the 3 targeted surveillance procedures. Data collected between 2013 and 2016 were analyzed to account for a definition change in 2013.

Results:

For the 3 targeted surveillance procedures, IP reviewed 2,255 procedures and identified 43 SSIs. For the remaining procedures, IPs identified 123 SSIs confirmed by one or more pathogens. The overall SSI rate had a 31% decrease. The cardiovascular and spinal fusion SSI rate had a 61% and 84% decrease, respectively. The ventricular shunt SSI rate increased 29% due to 2 episodes of recurrent infections in 2 patients.

Conclusions:

It is prudent for hospitals to continue monitoring SSI by establishing surveillance programs with optimal approaches.
A Quality Improvement Intervention to Decrease Hypothermia in the Delivery Room Using a Checklist
Authors: Vinci Alexandra , Islam Shahidul , Quintos-Alegheband Lyn , Hanna Nazeeh , Nayak Amrita
Published: June 2019

Introduction:

Premature babies are at increased risk of hypothermia, core body temperature <97°F. Delivery room environment may contribute and lead to complications. The objective was to reduce hypothermia in babies <32 weeks of gestation in the delivery room to <40% using a checklist and sustain it for 6 months.

Methods:

We created a delivery room checklist in 2012. Chart review established a baseline rate of hypothermia (<97°F). The team analyzed the checklist’s effect on hypothermia from 2012 to 2018 and utilized numerous interventions to maintain compliance. Chi-square test and Fisher’s exact test analyzed hypothermia and hyperthermia as a balancing measure. All calculations performed in SAS 9.3.

Results:

The checklist reduced hypothermia from a baseline of 50% in 2011 (n = 104) to 33% in 2012 (n = 106). In 2013, the proportion of hypothermia slightly increased to 36% (n = 81). The year 2014 brought larger drift, and proportion of hypothermia increased to 44% (n = 117). In 2015, we reinforced the use of the checklist and proportion of hypothermia improved to 36% (n = 99). Further interventions through 2018 decreased hypothermia further to 14% to achieve statistical significance.

Conclusions:

A checklist is a simple tool that may yield beneficial changes in practice and helped to decrease the proportion of neonatal hypothermia.
Development of a Standardized Approach for the Assessment of Bowel and Bladder Dysfunction
Authors: Wang Rebecca , Kanani Ronik , El Bardisi Yara , Mistry Niraj , Dos Santos Joana
Published: June 2019

Introduction:

Bowel and bladder dysfunction (BBD) is a common pediatric condition that describes a constellation of lower urinary tract symptoms (LUTS) associated with constipation. Many children with BBD have comorbid neuropsychiatric and psychosocial concerns that are not routinely assessed. The aim of quality improvement (QI) was to establish a comprehensive assessment for BBD by developing and evaluating (1) a standardized clinician assessment form and (2) parent-reported questionnaire.

Methods:

From July 2017 to April 2018, a prospective QI study was conducted in the BBD network. A standardized assessment form was developed based on literature review and expert opinions, with targeted sections for LUTS, constipation, and psychosocial history. Before clinic, families of children referred for BBD were given a questionnaire to clarify voiding, stooling, and dietary patterns. Physicians utilized the assessment form for new referrals. Afterward, both physicians and parents evaluated the assessment process anonymously.

Results:

A total of 15 physicians and 45 parents responded, with 67% of patients being between 4 and 10 years old and 51% male. Physicians responded that the assessment form reminded them to ask about specific LUTS (93%), constipation (87%), and psychosocial history (87%). Parents responded positively by agreeing that they felt included in care decisions (96%) and had questions answered appropriately (100%). Only 47% found the previsit package easy to complete.

Conclusions:

In pediatric BBD consultations, a standardized assessment form can guide clinicians to efficiently gather a comprehensive history and screen for psychosocial risk factors. It can empower more pediatricians to evaluate BBD in the future.
Improving Thermal Support in Very and Extremely Low Birth Weight Infants during Interfacility Transport
Authors: McNellis Emily M. , Leonard Amy R. , Thornton Kimberly A. , Voos Kristin C.
Published: June 2019

Introduction:

Review of very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates transported by our specialized pediatric/neonatal transport team revealed hypothermia in up to 52% of admissions. This project aimed to decrease the incidence of hypothermia in VLBW and ELBW neonates requiring transport between facilities from 52% to <20% over 1 year.

Methods:

In response to gaps in knowledge and barriers to care revealed by a survey administered to transport personnel, we used a standard quality improvement plan-do-study-act model to introduce new equipment and a comprehensive thermoregulation protocol via standardized education. The primary outcome measure was the incidence of hypothermia (axillary temperature < 36.5°C) in transported VLBW and ELBW neonates. The process measure was compliance with the protocol. The balancing measures were unintended hyperthermia and transport team ground time. Transport personnel were updated on progress via meetings and run charts.

Results:

We reduced the incidence of hypothermia to 17% in 1 year. Compliance with the protocol improved from 60% to 76%. There was no increase in unintended hyperthermia (5% preintervention, 4% intervention, 7% surveillance, P = 0.76) or transport team ground time (in hours) (1.2 ± 0.9 preintervention versus 1.3 ± 0.8 intervention versus 1.2 ± 0.7 surveillance, P = 0.2).

Conclusions:

Quality improvement methods were used to develop an evidence-based, standardized approach to thermal support in VLBW and ELBW neonates undergoing transport between facilities. Following the implementation of this approach, we achieved the desired percent decrease in the incidence of hypothermia.
Impacting Satisfaction, Learning, and Efficiency Through Structured Interdisciplinary Rounding in a Pediatric Intensive Care Unit: A Quality Improvement Project
Authors: Lopez Merrick , Vaks Yana , Wilson Michele , Mitchell Kenneth , Lee Christina , Ejike Janeth , Oei Grace , Kaufman Danny , Hambly Jamie , Tinsley Cynthia , Bahk Thomas , Samayoa Carlos , Pappas James , Abd-Allah Shamel
Published: June 2019

Background:

Daily rounds in many pediatric intensive care units (PICUs) vary in quality, duration, and participation. We hypothesized that implementing structured interdisciplinary bedside rounds (SIBR®) would improve our rounding process.

Methods:

This was a quality improvement initiative in a 25-bed multidisciplinary PICU in a tertiary children’s hospital. Baseline data included rounding duration; participation of nurses, respiratory care practitioners (RCP), parents; and physician order read-back practices. Interventions were implementing pre-rounding huddles, changing the start of the rounding week, and instituting a SIBR model. All staff, consecutive patients and parents participated over 18 months. We used Mann-Whitney, z-test, and t-tests for statistical analysis with a significance level of 0.05. We tracked data with a statistical process control chart.

Results:

Rounds participation increased for nurses (88% to 100%), RCPs (13% to 61%), and families (24% to 49%) (all p <0.001). Physician order read-back increased (41% to 79%) (p<0.001). The median length of stay (LOS) decreased from 2.1 to 1.9 days (p=0.004) with no changes in mortality or readmissions. The proportion of top responses from family surveys increased from 0.69 to 0.76 (p<0.001). PICU rounding duration (minutes/patient) decreased from 17.1 to 11.3. Most resident physicians felt SIBR positively impacted their education (70%), was more effective than rounds without structure (97%), and that family presence positively impacted learning (70%).

Conclusions:

Implementing a SIBR process in our PICU resulted in greater family and staff satisfaction, improved workflow and decreased rounding time by 34% without compromising education. LOS decreased significantly with no increases in mortality or readmissions.
Eating junk-food has opposite effects on intrinsic excitability of nucleus accumbens core medium spiny neurons in obesity-susceptible vs. -resistant rats
Authors: Oginsky Max F. , Ferrario Carrie R.
Published: June 2019

The nucleus accumbens (NAc) plays critical roles in motivated behaviors, including food-seeking and feeding. Differences in NAc function contribute to over-eating that drives obesity, but the underlying mechanisms are poorly understood. In addition, there is a fair degree of variation in individual susceptibility vs. resistance to obesity that is due in part to differences in NAc function. For example, using selectively bred obesity-prone and obesity-resistant rats, we have found that excitability of medium spiny neurons within the NAc core is enhanced in obesity-prone vs. resistant populations, prior to any diet manipulation. However, it is unknown whether consumption of sugary, fatty junk-food alters MSN excitability. Here, whole-cell patch clamp recordings were conducted to examine MSN intrinsic excitability in adult male obesity-prone and obesity-resistant rats with and without exposure to a sugary, fatty junk-food diet. We replicated our initial finding that basal excitability is enhanced in obesity-prone vs. obesity-resistant rats and determined that this is due to a lower IA in prone vs. resistant groups. In addition, the junk-food diet had opposite effects on excitability in obesity-prone vs. obesity-resistant rats. Specifically, junk-food enhanced excitability in MSNs of obesity-resistant rats; this was mediated by a reduction in IA. In contrast, junk-food reduced excitability in MSNs from obesity-prone rats; this was mediated by an increase in IKIR. Thus, individual differences in obesity-susceptibility influence both basal excitability and how MSN excitability adapts to junk-food consumption.
A Web Service for Assessing Insect Abundances for Meadow Birds by Image Analysis
Authors: Michels Ricardo , Vos Rutger
Published: June 2019

Abstract

Meadow birds are a group of species native to the Netherlands characterized by breeding in meadows that has been in decline over the last several decades, despite widespread conservation efforts. Agricultural intensification is thought to be one of the main causes of this decline, but no yearly data exists on the surrounding ecology of these birds. Recent efforts have tried to assess the food supply of meadow birds by setting sticky traps and counting the number of insects caught on them. However, this approach cannot be applied on a large scale since counting the insects is very labour intensive and unappealing to the volunteers that contribute to this research. To get a better assessment of the food supply at a larger scale, we present a system to automate counting of insects on sticky traps. The system is intended to process uploaded images and metadata using computer vision techniques to determine the number of insects found in photographs taken from the sticky traps.
An intact keratin network is crucial for mechanical integrity and barrier function in keratinocyte cell sheets
Authors: Karsch Susanne , Büchau Fanny , Magin Thomas M. , Janshoff Andreas
Published: June 2019

The isotype-specific composition of the keratin cytoskeleton is important for strong adhesion, force resilience, and barrier function of the epidermis. However, the mechanisms by which keratins regulate these functions are still incompletely understood. In this study, the role and significance of the keratin network for mechanical integrity, force transmission, and barrier formation were analyzed in murine keratinocytes. Following the time-course of single-cell wounding, wildtype (WT) cells slowly closed the gap in a collective fashion involving tightly connected neighboring cells. In contrast, the mechanical response of neighboring cells was compromised in keratin-deficient cells, causing an increased wound area initially and an inefficient overall wound closure. Furthermore, the loss of the keratin network led to impaired, fragmented cell-cell junctions and triggered a profound change in the overall cellular actomyosin architecture. Electrical cell-substrate impedance sensing of cell junctions revealed a dysfunctional barrier in knockout (Kty−/−) compared to WT cells. These findings demonstrate that Kty−/−cells display a novel phenotype characterized by loss of mechanocoupling and failure to form a functional barrier. Re-expression of K5/K14 rescued the barrier defect to a significant extent and reestablished the mechanocoupling with remaining discrepancies likely due to the low abundance of keratins in that setting. Our study reveals the major role of the keratin network for mechanical homeostasis and barrier functionality in keratinocyte layers.