bluuebunny/crossref_metadata_2025 huggingface dataset:
GenPipes: an open-source framework for distributed and scalable genomic analyses
Authors: Bourgey Mathieu , Dali Rola , Eveleigh Robert , Chen Kuang Chung , Letourneau Louis , Fillon Joel , Michaud Marc , Caron Maxime , Sandoval Johanna , Lefebvre Francois , Leveque Gary , Mercier Eloi , Bujold David , Marquis Pascale , Van Patrick Tran , Anderson de Lima Morais David , Tremblay Julien , Shao Xiaojian , Henrion Edouard , Gonzalez Emmanuel , Quirion Pierre-Olivier , Caron Bryan , Bourque Guillaume
Published: June 2019

Background

With the decreasing cost of sequencing and the rapid developments in genomics technologies and protocols, the need for validated bioinformatics software that enables efficient large-scale data processing is growing.

Findings

Here we present GenPipes, a flexible Python-based framework that facilitates the development and deployment of multi-step workflows optimized for high-performance computing clusters and the cloud. GenPipes already implements 12 validated and scalable pipelines for various genomics applications, including RNA sequencing, chromatin immunoprecipitation sequencing, DNA sequencing, methylation sequencing, Hi-C, capture Hi-C, metagenomics, and Pacific Biosciences long-read assembly. The software is available under a GPLv3 open source license and is continuously updated to follow recent advances in genomics and bioinformatics. The framework has already been configured on several servers, and a Docker image is also available to facilitate additional installations.

Conclusions

GenPipes offers genomics researchers a simple method to analyze different types of data, customizable to their needs and resources, as well as the flexibility to create their own workflows.
Genetic approaches to the treatment of inherited neuromuscular diseases
Authors: Ravi Bhavya , Antonellis Anthony , Sumner Charlotte J , Lieberman Andrew P
Published: June 2019

Inherited neuromuscular diseases are a heterogeneous group of developmental and degenerative disorders that affect motor unit function. Major challenges toward developing therapies for these diseases include heterogeneity with respect to clinical severity, age of onset and the primary cell type that is affected (e.g. motor neurons, skeletal muscle and Schwann cells). Here, we review recent progress toward the establishment of genetic therapies to treat inherited neuromuscular disorders that affect both children and adults with a focus on spinal muscular atrophy, Charcot–Marie–Tooth disease and spinal and bulbar muscular atrophy. We discuss clinical features, causative mutations and emerging approaches that are undergoing testing in preclinical models and in patients or that have received recent approval for clinical use. Many of these efforts employ antisense oligonucleotides to alter pre-mRNA splicing or diminish target gene expression and use viral vectors to replace expression of mutant genes. Finally, we discuss remaining challenges for optimizing the delivery and effectiveness of these approaches. In sum, therapeutic strategies for neuromuscular diseases have shown encouraging results, raising hope that recent strides will translate into significant clinical benefits for patients with these disorders.
Fostering the growth of student start-ups from university accelerators: an entrepreneurial ecosystem perspective
Authors: Breznitz Shiri M , Zhang Qiantao
Published: June 2019

Despite their significance, firms created by students have been the subject of little research. Adopting the entrepreneurial ecosystem framework, this paper examines the growth of student start-ups, especially those that participate in university accelerators. Focused on the University of Toronto, this paper contributes to an understanding of how university accelerators can better support the entrepreneurial efforts of students. It is clear that firms that participate in accelerators with a screening process have a stronger performance in both employment and product growth. Moreover, a habitual entrepreneur director or a more intensive accelerator program is found to have more positive effects on product growth at firms than on employment growth.
Reflection on modern methods: when worlds collide—prediction, machine learning and causal inference
Authors: Blakely Tony , Lynch John , Simons Koen , Bentley Rebecca , Rose Sherri
Published: June 2019

Causal inference requires theory and prior knowledge to structure analyses, and is not usually thought of as an arena for the application of prediction modelling. However, contemporary causal inference methods, premised on counterfactual or potential outcomes approaches, often include processing steps before the final estimation step. The purposes of this paper are: (i) to overview the recent emergence of prediction underpinning steps in contemporary causal inference methods as a useful perspective on contemporary causal inference methods, and (ii) explore the role of machine learning (as one approach to ‘best prediction’) in causal inference. Causal inference methods covered include propensity scores, inverse probability of treatment weights (IPTWs), G computation and targeted maximum likelihood estimation (TMLE). Machine learning has been used more for propensity scores and TMLE, and there is potential for increased use in G computation and estimation of IPTWs.
Minimal Generators of Hall Algebras of 1-cyclic Perfect Complexes
Authors: Zhang Haicheng
Published: June 2019

Let $A$ be the path algebra of a Dynkin quiver over a finite field, and let $C_1(\mathscr{P})$ be the category of 1-cyclic complexes of projective $A$-modules. In the present paper, we give a PBW-basis and a minimal set of generators for the Hall algebra ${\mathcal{H}}\,(C_1(\mathscr{P}))$ of $C_1(\mathscr{P})$. Using this PBW-basis, we firstly prove the degenerate Hall algebra of $C_1(\mathscr{P})$ is the universal enveloping algebra of the Lie algebra spanned by all indecomposable objects. Secondly, we calculate the relations among the generators in ${\mathcal{H}}\,(C_1(\mathscr{P}))$, and obtain quantum Serre relations in a quotient of certain twisted version of ${\mathcal{H}}\,(C_1(\mathscr{P}))$. Moreover, we establish relations between the degenerate Hall algebra, twisted Hall algebra of $A$ and those of $C_1(\mathscr{P})$, respectively.
Effects of dietary exogenous fibrolytic enzymes on ruminal fermentation characteristics of beef steers fed high- and low-quality growing diets1
Authors: Kondratovich Lucas B , Sarturi Jhones O , Hoffmann Carly A , Ballou Michael A , Trojan Sara J , Campanili Pedro R B
Published: June 2019

The effects of dietary pretreatment with fibrolytic enzyme-based cocktail were evaluated in 2 studies: (1) in vitro true digestibility; and (2) intake, digestibility, feeding behavior, and ruminal fermentation of beef steers fed growing diets. For the in vitro assessment, the ruminal inoculum was collected from 2 steers (BW = 543 ± 45 kg; 4-h after feeding; growing diets) and enzymes included or not (Trichoderma reesei fermentation extract; 0.75 µL/g of substrate DM). Within in vitro batches (n = 4), 12 substrates were incubated and in vitro true nutrient digestibility was evaluated. For study 2, 5 ruminally cannulated beef steers (BW = 520 ± 30 kg) were used in a 5 × 4 unbalanced Latin square using a 2 × 2 factorial arrangement of treatments: (a) diet quality (high = HQ; and low = LQ) and (b) enzyme inclusion (0 or 0.75 mL/kg of diet DM). Steers were fed ad libitum during four 21-d periods consisting of 14-d of adaptation and 7-d of collections. An enzyme × substrate was observed (P < 0.01), in which DM, OM, and NDF disappearance of sorghum grain increased with enzymes addition. Addition of enzymes increased (P < 0.01) ADF digestibility for all substrates. No diet quality × enzyme (P ≥ 0.18) was observed for intake variables in study 2. Enzyme-fed steers increased (P ≤ 0.05) intake of DM, digestible DM, NDF, and ADF compared with steers not fed fibrolytic enzymes. Addition of enzyme did not affect (P ≥ 0.28) apparent total tract digestibility of beef steers. Steers fed HQ diets consumed more (P ≤ 0.04) DM, digestible DM and OM, and less (P ≤ 0.03) total and digestible fiber than steers fed LQ diets. Ruminal pH average decreased (P = 0.01) for steers fed HQ or enzyme-fed diets compared with other treatments. A tendency (P = 0.06) toward improved total VFA was observed on enzyme-fed steers with HQ diets, but not for LQ diets. The molar proportion of ruminal propionate increased (P = 0.01) when steers were fed enzyme. Steers fed HQ diets had greater (P < 0.01) propionate and valerate molar proportions, lower (P < 0.01) acetate and acetate:propionate ratio than steers fed LQ diets. In vitro methane and total gas production were not affected (P ≥ 0.50) by dietary treatments. Fibrolytic enzymes positively affected digestion of multiple roughage sources commonly fed to cattle and might have additional benefit when used on unprocessed sorghum grain. Fibrolytic enzymes in beef cattle growing diets stimulated intake and generated positive impacts on ruminal fermentation.
Surrounding Vegetation, Climatic Elements, and Predators Affect the Spatial Dynamics of Bemisia tabaci (Hemiptera: Aleyrodidae) in Commercial Melon Fields
Authors: Felicio Thiago Nunes Pinto , Costa Thiago Leandro , Sarmento Renato Almeida , Ramos Rodrigo Soares , Pereira Poliana Silvestre , da Silva Ricardo Siqueira , Picanço Marcelo Coutinho
Published: June 2019

Studying the spatial dynamics of pests allows the determination of abiotic and biotic factors affecting time and locations of pest attack to the crops. Such abiotic and biotic factors mainly include 1) climatic elements, 2) natural enemies, 3) phenological stage of plants, and 4) surrounding vegetation. Melon (Cucumis melo L. [Cucurbitales: Cucurbitaceae]) is among the most consumed fruit in the world, and the whitefly Bemisia tabaci (Gennadius) is among the main pests of this crop. This work aimed to determine the effects of surrounding vegetation, natural enemies, climatic elements, and stages of plants on the spatial dynamics of B. tabaci in commercial melon fields. Adult whitefly densities were monitored on four melon fields in a tropical climate region. Sampling location in crops was georeferenced. Experimental data were submitted to geostatistical analysis. The highest densities of B. tabaci occurred during hot periods experiencing lower rainfall, and when the surrounding area presented crops hosting B. tabaci, especially other melon farms. The density ratio of the predators (i.e., spiders and Geocoris sp.) were dependent on pest density. The pattern of field colonization by B. tabaci varies according to its density. Therefore, the surrounding vegetation, air temperature, and predators influence the spatial distribution of B. tabaci in melon fields. These results provide important information to melon farmers, assisting them to improve the management of B. tabaci in the field.
Adverse Outcomes Associated With Potentially Inappropriate Antibiotic Use in Heart Failure Admissions
Authors: Frisbee Jason , Heidel R Eric , Rasnake Mark S
Published: June 2019

Background

Acute decompensated heart failure (ADHF) can be confused with other conditions that cause dyspnea. Patients with ADHF are often simultaneously treated for community-acquired pneumonia (CAP), even when evidence for infection is lacking. We hypothesized that the fluid and sodium content of potentially unnecessary intravenous antibiotic (IVAB) therapy could worsen outcomes of ADHF patients.

Methods

We reviewed 144 ADHF patients at low risk of pneumonia based on diagnostic findings and clinical documentation. The primary end point was length of stay. Secondary outcomes were mortality, readmission rates, amount of diuretic received, and fluid volume and quantity of sodium administered as part of IVAB therapy.

Results

Of the 144 admissions reviewed, 88 did not and 56 did receive IVAB. IVAB-treated patients received an average of 1.7 L of additional fluid (230 mL/d) and 9311 mg of additional sodium (1381 mg/d) as a result of IVAB therapy. Length of stay was longer in the IVAB arm (6.6 days) compared with the no-IVAB arm (3.0 days; P < .001). Patients required more furosemide in the IVAB arm (930 mg) compared with the no-IVAB arm (320 mg; P < .001). Patients who received IVAB were also 2.51 times more likely to be readmitted compared with patients who did not receive IVAB (P = .04).

Conclusions

ADHF patients who received IVAB without evidence of infection had longer lengths of stay, required more diuretics, and were more likely to be readmitted compared with ADHF patients not exposed to IVAB. ADHF patients are a promising target of antibiotic stewardship interventions.
Adaption of human antibody λ and κ light chain architectures to CDR repertoires
Authors: van der Kant Rob , Bauer Joschka , Karow-Zwick Anne R , Kube Sebastian , Garidel Patrick , Blech Michaela , Rousseau Frederic , Schymkowitz Joost
Published: June 2019

Monoclonal antibodies bind with high specificity to a wide range of diverse antigens, primarily mediated by their hypervariable complementarity determining regions (CDRs). The defined antigen binding loops are supported by the structurally conserved β-sandwich framework of the light chain (LC) and heavy chain (HC) variable regions. The LC genes are encoded by two separate loci, subdividing the entity of antibodies into kappa (LCκ) and lambda (LCλ) isotypes that exhibit distinct sequence and conformational preferences. In this work, a diverse set of techniques were employed including machine learning, force field analysis, statistical coupling analysis and mutual information analysis of a non-redundant antibody structure collection. Thereby, it was revealed how subtle changes between the structures of LCκ and LCλ isotypes increase the diversity of antibodies, extending the predetermined restrictions of the general antibody fold and expanding the diversity of antigen binding. Interestingly, it was found that the characteristic framework scaffolds of κ and λ are stabilized by diverse amino acid clusters that determine the interplay between the respective fold and the embedded CDR loops. In conclusion, this work reveals how antibodies use the remarkable plasticity of the beta-sandwich Ig fold to incorporate a large diversity of CDR loops.
User-defined single pot mutagenesis using unamplified oligo pools
Authors: Medina-Cucurella Angélica V , Steiner Paul J , Faber Matthew S , Beltrán Jesús , Borelli Alexandra N , Kirby Monica B , Cutler Sean R , Whitehead Timothy A
Published: June 2019

User-defined mutagenic libraries are fundamental for applied protein engineering workflows. Here we show that unamplified oligo pools can be used to prepare site saturation mutagenesis libraries from plasmid DNA with near-complete coverage of desired mutations and few off-target mutations. We find that oligo pools yield higher quality libraries when compared to individually synthesized degenerate oligos. We also show that multiple libraries can be multiplexed into a single oligo pool, making preparation of multiple libraries less expensive and more convenient. We provide software for automatic oligo pool design that can generate mutagenic oligos for saturating or focused libraries.
Type II DFT solutions from Poisson–Lie $T$-duality/plurality
Authors: Sakatani Yuho
Published: June 2019

String theory has $T$-duality symmetry when the target space has Abelian isometries. A generalization of $T$-duality, where the isometry group is non-Abelian, is known as non-Abelian $T$-duality, which works well as a solution-generating technique in supergravity. In this paper we describe non-Abelian $T$-duality as a kind of $\text{O}(D,D)$ transformation when the isometry group acts without isotropy. We then provide a duality transformation rule for the Ramond–Ramond fields by using the technique of double field theory (DFT). We also study a more general class of solution-generating technique, the Poisson–Lie (PL) $T$-duality or $T$-plurality. We describe the PL $T$-plurality as an $\text{O}(n,n)$ transformation and clearly show the covariance of the DFT equations of motion by using the gauged DFT. We further discuss the PL $T$-plurality with spectator fields, and study an application to the $\text{AdS}_5\times\text{S}^5$ solution. The dilaton puzzle known in the context of the PL $T$-plurality is resolved with the help of DFT.
Impact of overweight or obesity trajectory on health expenditure in Korea
Authors: Kim T H , Han E
Published: June 2019

Background

This study aimed to identify the effect of the overweight or obesity (OWOB) trajectory on current health care expenditure in South Korea.

Methods

Ten years of publicly released data (2002–12) were obtained in 2016 from a retrospective cohort of National Health Insurance System claims. This study included 51,844 adults (aged 30–59 years in 2002) and 21,196 elderly adults (aged ≥ 60 years in 2002).

Results

Compared with adults who maintained normal weight (NW), higher yearly total health expenditures were estimated for adults who lost weight over the 10-year period: by 11.5% (95% confidence interval (CI): 0.18–22.96%) when changing from NW to underweight (UW) and 6.2% (95% CI: 0.47–12.01%) from OWOB to UW/NW. Elderly adults had higher health expenditures when they lost weight by 14.0% (95% CI: 0.37–27.70%) from NW to UW and 6.8% (95% CI: 0.13–13.51%) from OWOB to UW/NW compared with when they maintained NW.

Conclusions

These findings indicate the importance of early intervention to control OWOB, particularly because people in late adulthood have greater health care needs for reasons other than OWOB.
‘Life is about risk management’: lay finance and the generalization of risk thinking to nonfinancial domains
Authors: Ailon Galit
Published: June 2019

This article examines the financial discourse on insecurity using a case study of the promotion of lay finance in Israel. Based on an analysis of financial courses, conferences, online texts and books that are designed for the lay public, the analysis shows that promoters of financial market engagements use everyday stories of marital and work-related insecurities—stories of divorce, betrayal, abandonment, unemployment and the like—to illustrate that economic risks are ubiquitous. Their stories render risk-thinking a general practice of knowing that is applicable to everyday life. At the same time, the stories shift the focus from the statistical meaning to the symbolic meaning of the risks taken. They present the risks of key social institutions as symbols of personal weakness, helplessness or humiliation, and grant the impersonal risks of financial markets a relative advantage. Analysing these findings from the perspective of the sociology of knowledge, I argue that lay financial discourse marks a radicalization of neoliberal discourse as studied by Foucault and that it is characterized by a much broader deconstructive scope than currently acknowledged. Its focus on frightening insecurities deconstructs the social knowledge that constitutes key institutions, exacerbating and feeding on their dissolution.
Respiratory costs of producing and maintaining stem biomass in eight co-occurring tree species
Authors: Rodríguez-Calcerrada Jesús , Salomón Roberto L , Gordaliza Guillermo G , Miranda José C , Miranda Eva , de la Riva Enrique G , Gil Luis
Published: June 2019

Given the importance of carbon allocation for plant performance and fitness, it is expected that competition and abiotic stress influence respiratory costs associated with stem wood biomass production and maintenance. In this study, stem respiration (R) was measured together with stem diameter increment in adult trees of eight co-occurring species in a sub-Mediterranean forest stand for 2 years. We estimated growth R (Rg), maintenance R (Rm) and the growth respiration coefficient (GRC) using two gas exchange methods: (i) estimating Rg as the product of growth and GRC (then Rm as R minus Rg) and (ii) estimating Rm from temperature-dependent kinetics of basal Rm at the dormant season (then Rg as R minus Rm). In both cases, stem basal-area growth rates governed intra-annual variation in R, Rg and Rm. Maximum annual Rm occurred slightly before or after maximum Rg. The mean contribution of Rm to R during the growing season ranged from 56% to 88% across species using method 1 and from 23% to 66% using method 2. An analysis accounting for the phylogenetic distance among species indicated that more shade-tolerant, faster growing species exhibited higher Rm and Rg than less shade-tolerant, slower growing ones, suggesting a balance between carbon supply and demand mediated by growth. However, GRC was not related to species growth rate, wood density, or drought and shade tolerance across the surveyed species nor across 27 tree species for which GRC was compiled. The GRC estimates based on wood chemical analysis were lower (0.19) than those based on gas exchange methods (0.35). These results give partial support to the hypothesis that wood production and maintenance costs are related to species ecology and highlight the divergence of respiratory parameters widely used in plant models according to the methodological approach applied to derive them.
Women in surgery: challenges and opportunities
Authors: de Costa Josephine , Chen-Xu José , Bentounsi Zineb , Vervoort Dominique
Published: June 2019

Women have been involved in surgery throughout history. However, despite the fact that there are now as many female medical students compared with male students in universities, men still significantly outnumber women in a number of procedural specialties, most notably surgery. This article discusses the factors that can influence women’s choice of surgical career, and the challenges and discrimination that women can face as surgeons. There is a strong argument for substantive policy change at the individual, organizational, and governmental level to reduce gendered discrimination and gendered stereotypes in surgery. We call upon all organizations involved in surgery, and particularly in the emerging field of global surgery, to actively work toward equity.
Standardization of Postoperative Transitions of Care to the Pediatric Intensive Care Unit Enhances Efficiency and Handover Comprehensiveness
Authors: Sochet Anthony A. , Siems Ashley , Ye Grace , Godiwala Nihal , Hebert Lauren , Corriveau Christiane
Published: June 2019

Introduction:

To determine the impact of standardization of postoperative transitions of care to the pediatric intensive care unit on handover efficiency and the quality of healthcare data exchange.

Methods:

This was a prospective, pre–post observational study after standardization of postoperative transitions in a 44-bed pediatric intensive care unit in a 313-bed tertiary care pediatric hospital from April to July 2015. Standardization was completed using a multidisciplinary handover checklist. Primary outcomes were efficiency expressed as mean handover duration and the comprehensiveness of healthcare data exchange.

Results:

Forty-seven postoperative transitions were observed of which 23 were preintervention and 24 were postintervention. After standardization, efficiency improved from 10.5 ± 5.4 to 7.8 ± 2.7 minutes (P < 0.05). Healthcare data exchanged between surgical, anesthesia, and critical care providers were more robust including intraoperative, historical, and anticipatory guidance (all P < 0.05). After intervention, attendance through completion of handover for surgical services increased from 13% to 88% (P < 0.05).

Conclusions:

Standardization of postoperative transitions improved efficiency, healthcare data exchange, and anticipatory planning. Future research is required to link standardization of transitions to improved patient outcomes and measure the development of shared mental models.
Return to Drive Counseling After Sports-Related Concussion: A Quality Improvement Project
Authors: Stuart Emily A. , Duerson Drew H. , Rodenberg Richard E. , Ravindran Reno , MacDonald James P.
Published: June 2019

Introduction:

Concussion is a common injury in adolescent athletes, many of whom also drive. Counseling athletes and their families about driving risks post concussion is a potentially significant intervention. The aim of this quality improvement project was to increase driving recommendations for concussed athletes in a pediatric sports medicine clinic.

Methods:

Patients in this quality improvement project were seen in the sports medicine concussion clinic between February 2014 and August 2015. We determined how often driving recommendations were documented through a retrospective chart review. Once the “return to drive” project was introduced to the sports medicine staff, multiple interventions were completed including handing out flyers to remind families about driving and creating changes to the electronic medical record.

Results:

At baseline, 9.3% of visits had driving recommendations documented. After an intervention requiring clinical documentation in the electronic medical record, 97% of patients received driving recommendations.

Conclusions:

The quality improvement effort was successful at increasing the frequency of delivery of appropriate driving recommendations provided to concussed athletes.
Optimizing a Nurse-led Transitional Home Visit Program in Preparation for a Randomized Control Trial
Authors: Sauers-Ford Hadley S. , Tubbs-Cooley Heather , Statile Angela M. , Pickler Rita H. , White Christine M. , Wade-Murphy Susan , Gold Jennifer M. , Shah Samir S. , Simmons Jeffrey M. ,   On behalf of the H2O Study Group
Published: June 2019

Introduction:

The Hospital to Home Outcomes study began with the end goal of evaluating the effectiveness of a single, nurse-led transitional home visit (home visit) program, for acutely ill, pediatric patients, which had been piloted at our institution. As part of the overall study design, building on prior randomized control trials that utilized a run-in period prior to the trial, our study team designed an optimization period to test the home visit and study procedures under real-world conditions.

Methods:

For this optimization project, there were 3 process improvement goals: to improve the referral process to the home visit, to optimize the home visit content, and to define and operationalize measures of patient- and family-centered outcomes to be used in the subsequent randomized control trial. During the optimization period, a multidisciplinary study team met weekly to review family and stakeholder feedback about the iterative modifications made to the home visit process, content, and outcome measures.

Results:

Optimization home visits were completed with 301 families across a variety of discharge diagnoses. The outcomes planned for the clinical trial were tested and refined. Feedback from families and stakeholders indicated that the content changes made to the home visits resulted in increased family knowledge of warning signs to monitor postdischarge. Thirty-one percent of families reported that they altered the care of their child after the home visit.

Conclusion:

Through iterative testing, informed by multistakeholder feedback, we leveraged patient and family engagement to maximize the effectiveness and generalizability of the home visit intervention.
Is the “July Effect” Real? Pediatric Trainee Reported Medical Errors and Adverse Events
Authors: Shah Ankoor Y. , Abreo Andrew , Akar-Ghibril Nicole , Cady Rebecca F. , Shah Rahul K.
Published: June 2019

Introduction:

The “July Effect” suggests an increase in patient adverse events in July compared with other months due to the introduction of new providers throughout the training continuum. The aim of this initiative was to analyze reported pediatric trainee medical errors from May through September 2015 at a tertiary care free-standing academic children’s hospital to determine if there were more reported medical errors and more adverse events from those errors in July.

Methods:

An error surveillance system is used to report and track near misses, adverse events, and medical errors. Three of the authors reviewed each report, which was electronically collected in the institution during the time period of interest. The reported medical error incidence per 1,000 trainee-days was compared against those in July for a significant difference.

Results:

There are a total of 282 trainees (86 pediatric residents, 81 nonpediatric residents, and 115 fellows) who are clinically active in the hospital at any given month. Pediatric residents had more reported medical errors in July (31) compared with May (16; P = 0.015), June (16; P = 0.019), and August (19; P = 0.046). There was no significant difference in the number of adverse events from reported medical errors by trainees in July (7) compared with May (5), June (8), August (4), or September (8; P > 0.2).

Conclusion:

In this single-center evaluation, there is an increase in reported medical errors involving pediatric residents in July compared with the months surrounding July. However, there is no difference in numbers of adverse events from those errors between these months.
An Intervention to Improve Caregiver Adherence to Oral Rehydration Therapy
Authors: Sundberg Melissa J. , Parver Stephanie , Morin Michele , Stack Anne M.
Published: June 2019

Objective:

To improve oral rehydration therapy (ORT) after discharge for children presenting to the emergency department (ED) with acute gastroenteritis (AGE).

Methods:

We designed and implemented a quality improvement initiative to improve caregiver adherence to ORT in children 6 months to 21 years old with AGE. The intervention consisted of ORT “kits” with rehydration supplies and caregiver instructions. In the preintervention period we monitored patient/caregiver adherence to ORT recommendations and additionally monitored ORT kit and educational material distribution during the intervention phase via a caregiver survey after discharge. We utilized statistical process control methodology to assess responses to the intervention. As a balancing measure, we monitored the ED length of stay for patients with AGE.

Results:

Over the study period from November 2013 to April 2015, we included 174 encounters during the preintervention period and 256 encounters during the intervention period. More than 9 of 10 children received ORT kits in the intervention period. Self-reported adherence to ORT between the 2 time periods remained constant. The ED length of stay did not change between the preintervention and intervention period.

Conclusions:

Despite successful distribution of novel ORT materials and education for caregivers of children with AGE in a pediatric ED, caregiver self-reported adherence to ORT postdischarge visit was unchanged. An unexpected high baseline adherence to ORT practices may have limited improvement.
Application of Conjoint Analysis to Improve Reliability of Dietician Consultation in Pediatric Celiac Disease
Authors: Kulkarni Sakil , Liss Kim , Samson Charles M.
Published: June 2019

Introduction:

Celiac disease (CD) management involves lifelong adherence to a gluten-free diet, making the dietician a key member in CD care. However, our institution lacked a standardized process for dietary consultation in newly diagnosed CD.

Methods:

To understand provider CD care preferences, a 24-1 fractional factorial conjoint analysis was performed. Attributes studied (2 levels each) included type of initial follow-up gastroenterology (GI) provider, interval from diagnosis to follow-up, concurrence of initial dietary consultation with gastroenterology visit, and on-going follow-up GI provider. CD care was standardized in July 2014 to facilitate concurrent visits with the clinician and dietician during the same clinical session. Changes to mean time of dietary consultation and reliability of dietary consultation were monitored using an individual-control and G-control chart, respectively. Standard control chart rules were followed.

Results:

Conjoint analysis identified shorter time to initial follow-up visit and concurrent GI/dietician visits as more important attributes in newly diagnosed CD subjects’ care. Types of follow-up provider during first or subsequent visits were identified as less important attributes. After initiation of a standardized follow-up process, a special cause was identified in December 2015 with a decrease in the mean time to dietary consultation from 30 to 20 days. In addition, standardized follow-up resulted in a more reliable process as evident by a special cause on the G-control chart in February 2015.

Conclusion:

Conjoint analysis identified attributes thought to be important in CD follow-up care. After redesign of our care process, a decrease in time to dietary consultation with improved reliability was observed.
Utilizing Lean Principles to Improve Immunization Administration Efficiency in a Pediatric Mobile Clinic Program
Authors: Gupta Aditi , Misra Sanghamitra M. , Garcia Cassandra , Ugalde Margaret
Published: June 2019

Introduction:

Mobile clinics are vital health care delivery systems because they provide care to those who may not have access otherwise. Unfortunately, clinic flow on mobile clinics is often chaotic and inherently inefficient. Lean is a customer-centric methodology used in industries like health care to continuously improve processes by eliminating waste. The purpose of this project was to use lean principles to improve efficiency, as measured by total time spent receiving services, so that more underserved patients could receive needed immunizations.

Methods:

Using a certified lean expert, lean principles were applied to the mobile clinic program to uniformly organize the program, simplify registration processes, and standardize clinic procedures. Time study data were collected prospectively on a total of 309 patients for 2-week periods both before and after application of lean principles. Staff used a standardized time study form to record patient visit times. Pre- and postintervention data were analyzed using unpaired t tests and nonparametric Mann-Whitney tests as deemed appropriate.

Results:

Using lean principles significantly reduced total times spent for 1-, 2-, and 4-children families. Wait times for 1- and 4-children families were also significantly decreased. Lastly, times spent on board the mobile clinic to receive immunizations for 1- and 3-children families were significantly decreased.

Conclusion:

Application of lean principles can improve efficiency by decreasing total time spent for patients receiving vaccine services on pediatric mobile clinics.
Development of Pediatric Emergency Protocols and Communication Plans in Pediatric Radiation Oncology: Multidisciplinary Core Competencies
Authors: Carson Rebecca A. , Ladra Matthew M. , Choflet Amanda
Published: June 2019

Radiation therapy is an essential component of treatment for many pediatric cancers, yet the cost of maintaining a radiation facility at a dedicated pediatric center is often prohibitive. As a result, adult facilities treat pediatric patients where preparation for a pediatric emergency may be inadequate. The purpose of this quality improvement project was to develop a multidisciplinary emergency preparedness plan for a collaborative pediatric radiation oncology program at an adult community hospital with its partnering academic children’s hospital. Using a cyclical process involving multidisciplinary collaboration that combines policy development, preparation, and team-building, the authors created the protocols and processes that would support the stabilization of a pediatric emergency and facilitate transfer to the partnering children’s hospital. Further development of a communication plan outlines the flow of patient information through the multidisciplinary team during these transitions of care. Areas for future work include quantitative outcome measures to determine the effectiveness of the policies and procedures developed to prepare staff for pediatric emergencies.
Reducing Antibiotic Use in Respiratory Syncytial Virus—A Quality Improvement Approach to Antimicrobial Stewardship
Authors: Quintos-Alagheband Maria Lyn , Noyola Estela , Makvana Sejal , El-Chaar Gladys , Wang Shan , Calixte Rose , Krilov Leonard R.
Published: June 2019

Objective:

The increased incidence of multidrug-resistant organisms is associated with increased morbidity, mortality, hospital length of stay, and cost. Estimates show that up to 50% of antimicrobial use is inappropriate. This initiative focuses on inappropriate use of antibiotics in respiratory syncytial virus (RSV) infections. This virus is the most common cause of bronchiolitis during childhood.

Methods:

Baseline data from the 2011–2012 RSV season showed that 56.2% of our RSV-positive patients received antibiotics. To decrease inappropriate antibiotic use in RSV infections, we established an antimicrobial stewardship program (ASP). This process improvement initiative aimed to decrease exposure to antibiotics and days of antibiotic therapy per 1,000 patient days (DOT/1000PD) in hospitalized RSV-positive patients by 25%. Key drivers included building health-care knowledge, proactive interventions using prospective audit and feedback, emergency department engagement, and performance dashboards.

Results:

We included a total of 290 children in the final analysis. After full implementation of the ASP, there was a significant reduction of antibiotic exposure from 56.2% to 30.9% (P < 0.001), an absolute reduction of 25% and a relative reduction of 45%. There was also a significant decrease in DOT/1000PD from 432.7 to 268.1 days (P = 0.017). This change represents a reduction of 164.6 DOT/1000PD from baseline after full ASP implementation.

Conclusion:

Despite the lack of a unified hospitalist group in our institution, we were successful in reducing inappropriate antibiotic use by focusing on standardizing care among different private pediatricians in the community. A multifaceted strategy and well-designed quality improvement methodology led to a sustained reduction in antibiotic use.
Improving Human Papilloma Virus Vaccination Rates: Quality Improvement
Authors: Bowden Michelle , Yaun Jason , Bagga Bindiya
Published: June 2019

Background:

Human papilloma virus (HPV) is a sexually transmitted infection with a national prevalence of greater than 70 million. Most infections are among persons 15–24 years of age. The HPV vaccine has nearly 100% efficacy when administered before natural exposure. However, national vaccination rates remain less than 50%. Our objective was to improve the rate of initiation of the HPV vaccination series in a resident teaching practice.

Methods:

We used the Plan Do Study Act methodology for quality improvement. Eligible patients included children 9 through 13 years of age who presented to a general pediatric clinic. We established baseline data by reviewing HPV immunization rates taken from a convenience sample of ≤20 patients per month over 7 months. A key driver diagram guided interventions including resident communication, nursing staff education, family knowledge, and an electronic medical record prompt beginning at age 9. Using standard run chart rules, we plotted monthly postintervention vaccination rates over 7 months of data collection.

Results:

Baseline data included 136 patients age 9–13. Run chart monitoring revealed an increase in our HPV vaccination rate from 53% at baseline to 62% by October 2015. Additionally, we observed a statistically significant increase in mean vaccination rates from 50% to 69% (odds ratio 2.071; P = 0.0042). We noted an increase in vaccination rates after resident education initiatives and after implementation of an electronic medical record prompt.

Conclusions:

Simple and practical interventions involving residents led to a marked increase in HPV vaccination in our patient population.
Using Length of Stay to Understand Patient Flow for Pediatric Inpatients
Authors: Stockwell David C. , Thomas Cherie , Fieldston Evan S. , Hall Matt , Czaja Angela S. , Stalets Erika L. , Biehler Jefry , Sheehan Maeve , Foglia Dorothy , Byrd Susan , McClead Richard E.
Published: June 2019

Objectives:

Develop and test a new metric to assess meaningful variability in inpatient flow.

Methods:

Using the pediatric administrative dataset, Pediatric Health Information System, that quantifies the length of stay (LOS) in hours, all inpatient and observation encounters with 21 common diagnoses were included from the calendar year 2013 in 38 pediatric hospitals. Two mutually exclusive composite groups based on diagnosis and presence or absence of an ICU hospitalization termed Acute Care Composite (ACC) and ICU Composite (ICUC), respectively, were created. These composites consisted of an observed-to-expected (O/E) LOS as well as an excess LOS percentage (ie, the percent of day beyond expected). Seven-day all-cause risk-adjusted rehospitalizations was used as a balancing measure. The combination of the ACC, the ICUC, and the rehospitalization measures forms this new metric.

Results:

The diagnosis groups in the ACC and the ICUC included 113,768 and 38,400 hospitalizations, respectively. The ACC had a median O/E LOS of 1.0, a median excess LOS percentage of 23.9% and a rehospitalization rate of 1.7%. The ICUC had a median O/E LOS of 1.1, a median excess LOS percentage of 32.3%, and rehospitalization rate of 4.9%. There was no relationship of O/E LOS and rehospitalization for either ACC or ICUC.

Conclusions:

This metric shows variation among hospitals and could allow a pediatric hospital to assess the performance of inpatient flow.
A Quality Improvement Initiative to Increase and Sustain Influenza Vaccination Rates in Pediatric Oncology and Stem Cell Transplant Patients
Authors: Wong Chris I. , Billett Amy L. , Weng Shicheng , Eng Kelly , Thakrar Usha , Davies Kimberly J.
Published: June 2019

Introduction:

Influenza vaccination of pediatric oncology and stem cell transplant (SCT) patients is crucial due to high risk of complications. Achieving high vaccination rates to prevent illness is often limited by competing demands and intensive treatment. A quality improvement (QI) initiative beginning influenza season 2012–2013 aimed to achieve and sustain high vaccination rates in active patients > 6 months of age, receiving cancer therapy or SCT within 6 months before or at any time during the season, and > 100 days after allogeneic SCT.

Methods:

We identified key drivers and barriers to success from an initially developed vaccination process that proved to be burdensome. Change ideas were implemented through multiple tests of change during the QI initiative. Iterations within and across 4 subsequent seasons included patient identification through chemotherapy orders, provider education, incorporating vaccination into routine work-flow, continuous data analysis and feedback, and use of new reporting technology.

Results:

Initial vaccination rates were < 70%, increasing to 89% after the QI initiative began and subsequently sustained between 85% and 90%. Active patients were significantly more likely to be vaccinated during the initiative (odds ratio, 3.7; 95% CI, 2.9–4.6) as compared with the first 2 seasons.

Conclusions:

High influenza vaccination rates can be achieved and maintained in a pediatric oncology/SCT population using strategies that correctly identify patients at highest risk and minimize process burden.
Electronically-augmented Huddle Improved Antibiotic Delivery for Sepsis in the Pediatric Intensive Care Unit
Authors: Woods-Hill Charlotte Z. , Biedron Lauren M. , Rigby Valerie A. , Kaminski Sharon , Papili Kelly E. , Fitzgerald Julie C. , Weiss Scott L.
Published: June 2019

Background:

Delayed antimicrobial therapy is an independent risk factor for mortality and prolonged organ dysfunction in sepsis. Barriers to timely antibiotic administration include lack of situational awareness about medication status and inconsistent communication with ordering clinicians.

Objectives:

The specific aim of this project was to achieve antibiotic administration within 60 minutes of order for ≥ 70% of suspected sepsis episodes in pediatric intensive care unit patients.

Methods:

In the 55-bed pediatric intensive care unit of an academic referral center, a standardized workflow to decrease antibiotic administration time for patients with suspected sepsis was iteratively implemented from 2012 to 2017. An electronic orderset (phase 1) and best practice alert for “stat” antibiotic ordering (phase 2) were combined with a scripted multidisciplinary bedside “sepsis huddle” (phase 3). Subsequently, a bedside, 1-touch electronic notification button was introduced (phase 4), which triggered automated phone alerts to the clinical team until antibiotic administration was complete (Fig. 1).

Results:

There was a progressive decrease in time from antibiotic order to administration from phase 1 through 4 (Table 1; Fig. 2). This improvement has been sustained, with ≥ 70% of suspected sepsis episodes meeting goal antibiotic administration time for 12 months following phase 4. On-time administration was more likely for episodes with versus without a huddle (90% versus 70%).

Conclusions/Implications:

Combining automated, timed reminders with a multidisciplinary huddle improved situational awareness about challenges to timely antibiotic delivery and decreased time to administration for critically ill children with suspected sepsis. Follow-up work includes integrating the 1-touch notification process into an automated sepsis recognition algorithm.
Time to Huddle: Initiating the Bedside Sepsis Huddle on an Acute Care Pediatric Unit
Authors: Lowerre Tracy S. , Silverman Jonathan A. , McGehee Jill M.
Published: June 2019

Background:

Rapid recognition and prompt treatment of sepsis within 1 hour may improve sepsis outcomes in children.

Objectives:

To develop and implement a sepsis screening tool and huddle process to improve early recognition and treatment of sepsis on an inpatient pediatric unit.

Methods:

Sepsis huddle implementation entailed house-wide education on early recognition of sepsis, antibiotic administration, and fluid bolus delivery methods. We used rapid Plan Do Study Act (PDSA) cycles to enhance documentation and communication among care providers during sepsis huddles. The team developed pocket cards for all team members to screen patients for sepsis based on Systemic Inflammatory Response Syndrome (SIRS) criteria (Goldstein, 2005). A paper huddle form was developed and adapted to ensure all the bundle elements were implemented within the 1 hour goal. We added a sepsis huddle section to the vital sign band of the electronic medical record. Standardized sepsis order sets ensured consistent care between the ED, inpatient units, and PICU.

Results:

Between April 24 and December 1, there were 112 huddles, 28 rapid response activations, and 14 immediate transfers to a higher level of care. The pediatric department met the goal of 70% of first dose STAT antibiotics administered within 1 hour. Our Vizient observed to expected sepsis mortality has dropped from 1.37 (FY 2016) to 0.99 (FY 2017, preliminary data). (Table 1)