bluuebunny/crossref_metadata_2025_split huggingface dataset:
Gravity analog model of non-equilibrium thermodynamics
Authors: Aibara Noriaki , Fujimoto Naoaki , Katagiri So , Saitou Mayumi , Sugamoto Akio , Yamamoto Takashi , Yumibayashi Tsukasa ,   The OUJ Tokyo Bunkyo Field Theory Collaboration
Published: June 2019

Abstract
The non-equilibrium thermodynamics of Onsager and Machlup and of Hashitsume is reformulated as a gravity analog model, in which thermodynamic variables, kinetic coefficients, and generalized forces form, respectively, coordinates and metric tensor and vector fields in a space of thermodynamic variables. The relevant symmetry of the model is the general coordinate transformation. Then, the entropy production is classified into three categories, when a closed path is depicted as a thermodynamic cycle. One category is time-reversal odd, and is attributed to the number of lines of magnetic flux passing through the closed path, having the monopole as a source. There are two time-reversal-even categories, one of which is attributed to the space curvature around the path, having the gravitational instanton as a source, which dominates for a rapid operation of the cycle. The last category is the usual one, which remains even for the quasi-equilibrium operation. It is possible to extend the model to include non-linear responses. In introducing new terms, dimensional counting is important, using two parameters, the temperature and the relaxation time. The effective action, being induced by the non-equilibrium thermodynamics, is derived. This is a candidate for the action that controls the dynamics of kinetic coefficients and thermodynamic forces. An example is given in a chemical oscillatory reaction in a solvent of van der Waals type. The fluctuation–dissipation theorem is examined à la Onsager, and a derivation of the gravity analog thermodynamic model from quantum mechanics is sketched, based on an analogy to the resonance problem.
A Case of Fasciolosis in a 11-Year-Old Syrian Immigrant Boy
Authors: Velev V , Vutova K , Pavlova M , Mangarov Iliya 
Published: June 2019

Abstract
Fasciolosis is a chronic parasitic disease caused by two species of liver trematodes, Fasciola hepatica and Fasciola gigantica, which infest ruminants and rarely humans. The disease is spread all over the world, but more common in Asia in areas with extensive livestock farming and can be imported cases in Europe and America. In this case, we describe imported infection with F. hepatica in Bulgaria from 11-year-old Syrian immigrant boy.
Tuberculosis control activities in the private and public health sectors of Kenya from 2013 to 2017: how do they compare?
Authors: Mailu Eunice W , Owiti Philip , Ade Serge , Harries Anthony D , Manzi Marcel , Omesa Eunice , Kiende Polly , Macharia Stephen , Mbithi Irene , Kamene Maureen 
Published: June 2019

Abstract

Background
Large numbers of tuberculosis (TB) patients seek care from private for-profit providers. This study aimed to assess and compare TB control activities in the private for-profit and public sectors in Kenya between 2013 and 2017.

Methods
We conducted a retrospective cross-sectional study using routinely collected data from the National Tuberculosis, Leprosy and Lung Disease Program.

Results
Of 421 409 patients registered and treated between 2013 and 2017, 86 894 (21%) were from the private sector. Data collection was less complete in the private sector for nutritional assessment and follow-up sputum smear examinations (p&lt;0.001). The private sector notified less bacteriologically confirmed TB (43.1% vs 52.6%; p&lt;0.001) and had less malnutrition (body mass index &lt;18.5 kg/m2; 36.4% vs 43.3%; p&lt;0.001) than the public sector. Rates of human immunodeficiency virus (HIV) testing and antiretroviral therapy initiation were &gt;95% and &gt;90%, respectively, in both sectors, but more patients were HIV positive in the private sector (39.6% vs 31.6%; p&lt;0.001). For bacteriologically confirmed pulmonary TB, cure rates were lower in the private sector, especially for HIV-negative patients (p&lt;0.001). The private sector had an overall treatment success of 86.3% as compared with the public sector at 85.7% (p&lt;0.001).

Conclusions
The private sector is performing well in Kenya although there are programmatic challenges that need to be addressed.
The Effects of Family Functioning on the Development of Posttraumatic Stress in Children and Their Parents Following Admission to the PICU*
Authors: Nelson Lara P. , Lachman Sage E. , Li Sara W. , Gold Jeffrey I. 
Published: June 2019

Objectives:
To report the rate of acute stress and posttraumatic stress among children and parents following PICU admission and the relation between family function and posttraumatic stress.

Design:
Prospective, longitudinal, multi-informant observational study. Pediatric patients (n = 69) and parents were recruited in the ICU. They completed measures evaluating acute stress and posttraumatic stress during their hospitalization and at 3-month follow-up. Parents completed measures of family functioning during the hospitalization. Pearson correlations and multiple regression models were used to examine the relations between family functioning and acute stress and posttraumatic stress.

Setting:
An academic, urban, pediatric hospital in California.

Patients:
Children, 8–17 years old, admitted to the PICU for greater than 24 hours and their English- or Spanish-speaking parents.

Interventions:
None.

Measurements and Main Results:
All children endorsed acute stress during their PICU admission, with 51% meeting criteria for acute stress disorder. At 3-month follow-up, 53% of the children continued to endorse posttraumatic stress with 13% meeting criteria for posttraumatic stress disorder. Among parents, 78% endorsed acute stress during admission with 30% meeting criteria for acute stress disorder, and at follow-up, 35% endorsed posttraumatic stress with 10% meeting criteria for posttraumatic stress disorder. In multiple linear regression modeling, child acute stress significantly predicted child posttraumatic stress (β = 0.36; p < 0.01). In the parent model, parent acute stress (β = 0.29; p < 0.01) and parent education (β = 0.59; p < 0.00) positively predicted parent’s posttraumatic stress. Family function was not a predictor of either’s posttraumatic stress.

Conclusions:
Both children and parents have alarmingly high rates of acute stress and posttraumatic stress following the child’s PICU admission. Although family function did not emerge as a predictor in this study, further understanding of the influence of the family and the interplay between child and parent posttraumatic stress is needed to improve our understanding of the model of development of posttraumatic stress in this population to inform the intervention strategies.
Antidepressant Use by Youth with Minimal or Mild Depression: Evidence from 3 Health Systems
Authors: Penfold Robert B. , Stewart Christine , Simon Gregory E. , Shortreed Susan M. , Johnson Eric , Rossom Rebecca C. , Operskalski Belinda , Beck Arne 
Published: June 2019

Background:
There is concern about the prevalence of prescribing antidepressant medications to youth without appropriate diagnoses or who have subthreshold (mild) depression.

Methods:
Electronic records data from 3 large healthcare systems identified youth aged ≤21 years starting a new episode of antidepressant treatment between January 1, 2009, and December 31, 2013. For those with a diagnosis of depression, Patient Health Questionnaire (PHQ9) scores at the time of treatment initiation were used to examine the distribution of symptom severity and patients' demographic and clinical characteristics.

Results:
Of the 15,460 episodes of treatment, a depression diagnosis was recorded in 95% of the cases. PHQ9 scores were available for 4,329 youth with a diagnosis of depression. Younger age, sex, previous treatment, co-occurring anxiety, treatment setting, concurrent psychotherapy, and site were significant predictors of completing a PHQ9. Among youth with a baseline score, 87% reported moderate or severe symptoms (PHQ9 score ≥ 10) and 13% reported mild or minimal symptoms (PHQ9 < 10). The proportion reporting PHQ9 < 10 when starting treatment decreased with age, ranging from 19% in those aged 13–14 years and 12% in those aged 18–21 years. Patients treated by psychiatrists were 1.54 times (95% Confidence Interval [CI], 1.21–1.97) more likely to have PHQ9 scores < 10 compared with primary care physicians. Patients with prior treatment history (odds ratio = 1.76; 95% CI, 1.45–2.13) and concurrent psychotherapy (odds ratio = 1.24; 95% CI, 1.02–1.52) were more likely to have PHQ9 < 10.

Conclusions:
In these health systems, prescribing of antidepressant medication to adolescents for minimal or mild depression is much less common than previous reported.
Implementation of an Outcome Measure in Pediatric Behavioral Health: A Process Improvement Initiative
Authors: Butz Catherine , Valleru Jahnavi , Castillo Anthony , Butter Eric M. 
Published: June 2019

Introduction:
Efforts to monitor outcomes in pediatric behavioral health are becoming a quality, financial, and regulatory imperative. The implementation of a broad-based measure to assess patient functioning at the start of pediatric psychology services, as well as at subsequent visits, has not been demonstrated. This article describes the systematic implementation of a measure of health-related quality of life (HRQOL) to assess functional impairment across an entire clinic population using quality improvement science and methodologies.

Methods:
The Pediatric Quality of Life Inventory Generic Core 4.0 (PedsQL) was administered at initial and subsequent visits for all patients seeking treatment at a large, tertiary care pediatric psychology clinic in an academic pediatric medical center (Nationwide Children’s Hospital, Columbus, Ohio). The goal of this project was to design a process change to support a 90% completion rate of this measurement tool by all clinicians.

Results:
Within 16 months, the completion rate of the PedsQL increased from a baseline of 39% to the identified goal of 90%. This process change was within control limits (over 80%) for over 12 months.

Conclusion:
This study demonstrates the implementation of a systematic process for collection of outcome measures in a pediatric behavioral health care setting. Successful administration of an outcome measure at multiple time points during the care of children and adolescents in a large psychology clinic can allow for quantitative assessment of treatment progress and identify a pathway for administration of additional measures.
SAFEST: Use of a Rubric to Teach Safety Reporting to Pediatric House Officers
Authors: Keefer Patricia , Helms Lauren , Warrier Kavita , Vredeveld Jennifer , Burrows Heather , Orringer Kelly 
Published: June 2019

Background:
Among the many modalities of error detection in academic pediatric hospitals, patient safety reporting is an important component, particularly for unexpected events. Residents recognize the importance of reporting but cite some barriers to doing so. A rubric was developed to guide resident reporting and streamline information gathering in patient safety reports. The rubric used the acronym SAFEST as a reminder to include 6 key elements:
1. Staff involved in the incident.
2. Actual event description.
3. Follow-up initiated.
4. Effect on patient.
5. Standard of care described.
6. To-do/suggestions for improvement.

Objectives:
This study was designed to determine if the addition of this educational rubric into a standard quality improvement curriculum improves the consistency of information documented in patient safety reports as a subset of a larger quality improvement project aimed at improving safety reporting.

Methods:
A team of faculty members analyzed individual resident error reports for adherence to the 6 tenets of the SAFEST mnemonic.

Results:
From April to October of 2014, 2015, and 2016, a convenience sample of 131, 110, and 132 reports, respectively, were extracted and analyzed. For the rates of reporting “staff involved” and “standard of care,” the differences over time were significant, both with P values < 0.001. After training, residents were 2.2 times more likely to report on the “staff involved” in the error and 1.8 times more likely to report the “standard of care.”

Discussion:
These results describe successful education on a rubric designed to improve the content of patient safety reports.
Increasing Patient Portal Activation in a Pediatric Subspecialty Clinic
Authors: Ratliff-Schaub Karen , Valleru Jahnavi 
Published: June 2019

Background:
Online patient portals are not widely used, despite their advantages for efficient communication, especially for patients with chronic conditions. A hospital-based group practice of Developmental-Behavioral Pediatricians initiated this quality improvement (QI) project with a goal to increase the percentage of patients with an active MyChart (Epic Systems Corporation’s patient portal) account and ultimately improve efficiency of communication between families and clinical staff.

Methods:
Using QI methodology, we identified staff commitment, workflow issues, and family awareness as gaps and implemented progressive Plan, Do, Study, Act cycles aimed at developing standard processes for activating families on MyChart. We tracked our project measures with statistical process control methodology and sustained our progress with improving awareness and regular feedback.

Results:
Patient portal activations increased from 1.8% to 30% in a 6-month time period. Highly successful interventions included development and implementation of a standard process for activation, staff education to ensure comfort and commitment, having families opt out instead of opt in, and completed activation of accounts before families leaving clinic.

Conclusions:
Patient portal activation can be significantly increased through systematic application of QI methodology to address staff training and workflow in a busy subspecialty clinic. Engagement of operations staff and completion of the activation process while the family is still in clinic seemed to be effective in getting families activated in MyChart. It is possible to improve patient portal activation with minimal impact to workflow.
Impact of Implementing a Pediatric Early Warning System (PEWS) in a Pediatric Oncology Hospital
Authors: Agulnik Asya , Johnson Sherry , Wilkes Regina , Faughnan Lane , Carrillo Angela , Morrison R. Ray 
Published: June 2019

Background:
Hospitalized pediatric oncology and hematopoietic stem cell transplant (HSCT) patients have frequent clinical deterioration requiring transfer to the Pediatric Intensive Care Unit (PICU). Pediatric Early Warning Systems (PEWS) can aid early identification of clinical deterioration and improve outcomes in these patients.

Objectives:
Describe the impact of PEWS implementation in a dedicated pediatric hematology-oncology/HSCT hospital.

Methods:
A PEWS tool and escalation algorithm were implemented between August and October 2016 (Fig. 1). Implementation quality was evaluated by measuring errors in PEWS calculation, omissions, and algorithm activation. Frequency of emergency activations and method of unplanned PICU transfer were compared before and after PEWS implementation.

Results:
Random monitoring of PEWS scores demonstrated 12.7% calculation errors, 3.8% omissions, and 1.7% algorithm errors. Omissions and algorithm errors decreased over time following implementation (P < 0.0001 and P = 0.005, respectively). Frequency of Rapid Response Team (RRT) activations increased after PEWS implementation from 1.3 to 12.2/1,000-inpatient-days (P < 0.0001), without an increase in Code Blue activations (1.2 to 0.97/1,000-inpatient-days, P = 0.49, Fig. 2) and no change in frequency of unplanned PICU transfers (5.7/1,000-inpatient-days before and after PEWS implementation). Unplanned PICU transfers arriving via RRT increased from 11.5% to 60.5% of admissions (P < 0.0001, Fig. 3).

Conclusions/Implications:
PEWS can be successfully implemented in a pediatric hematology-oncology/HSCT hospital with improvement in accuracy over time. Implementation of PEWS resulted in increased use of the RRT system and more patients with clinical deterioration arriving to the PICU via an organized escalation pathway, representing standardization of care and improvement in the culture of safety in the hospital.
Early Recognition of Sepsis among Inpatients in Pediatric Critical Care and Acute Care Areas
Authors: Brown Terri L. , Jeppesen Amy , Kancharla Venkatesh , Macias Charles 
Published: June 2019

Project Aim:
Develop, test, and implement inpatient clinical decision support tools (Best Practice Alerts; BPA) for early recognition of sepsis to improve time from physiologic sepsis to recognition, and timeliness of evidence-based care, with the ultimate goals of reducing mortality and morbidity.

Background:
No valid and reliable sepsis screening tools for hospitalized children exist. The Pediatric Septic Shock collaborative, focused on Emergency Centers, demonstrated reduced mortality with early intervention and improved adherence to evidence-based care bundles. Setting: large quaternary children’s hospital, average monthly severe sepsis volume: 148 children, 6 deaths.

Methods:
Existing pediatric sepsis screens were identified via literature review, Epic UserWeb, and Children’s Hospital Association Improving Pediatric Sepsis Outcomes Collaborative website. Our Emergency Center sepsis screen was selected as the base for our inpatient tools. Separate scoring criteria were developed for use in the Critical Care areas and Acute Care/Hematology-Oncology/Bone Marrow Transplant areas (Fig. 1).

Results:
The sepsis screening algorithms were implemented in the background of the electronic medical record, allowing performance testing in our populations before becoming visible to the end-user. Initial results of a 3-day test period of screening with 8-hour lockout are in Table 1.

Discussion:
The number of activations were not excessive. Multiple revisions to the BPA build were required due to the paucity of component details in the reporting for population analysis; however, these enriched data are pending.
Impact of a Hands-free Wireless Communication Device on Communication and Clinical Outcomes in a Pediatric Intensive Care
Authors: Cooney Hannah J. , Banbury Hannah E. , Plunkett Adrian C. 
Published: June 2019

Introduction:
Timely communication is essential in the intensive care environment. Delays may occur if communication relies on identification of individuals through line of sight, or use of telephones and pagers. We measured communication delays, staff perceptions, and clinical outcomes before and after implementation of a hands-free wireless communication device (HWCD) in a pediatric intensive care unit (PICU).

Methods:
Single-center study comprising 3 components: observational study of verbal communication among PICU staff; staff survey regarding perceptions of communication delays; analysis of clinical data (length of stay, risk adjusted mortality, emergency events). All components were conducted before and after implementation of the HWCD.

Results:
Four hundred sixteen hours of staff working time were observed (210 pre- and 206 postimplementation). These data showed significant reduction in communication delays—most notably among roaming staff [median time to response to verbal queries before and after implementation 120 seconds (interquartile range, 6–255) and 9 seconds (interquartile range, 7–30), respectively: P < 0.001]. The results of the staff survey showed significant improvements in staff perceptions of communication delays in all roaming staff groups utilizing the HWCD. The survey response rate was 205/361: 56.8%. There were no differences in clinical outcomes from the routinely collected clinical data. There was a significant reduction in emergency event rate—emergency summoning of assistance to bedside (per 100 bed-days)—before and after implementation, 2.17 and 1.69, respectively: rate ratio = 0.78 (95% confidence interval, 0.63–0.95; P < 0.05).

Conclusions:
Implementation of a HWCD was associated with significant reduction in communication delays among roaming staff members in PICU.
Standardized Process for Early Recognition and Treatment of Hypotension in Pediatric Oncology Patients Reduces Clinical Deterioration and Shock
Authors: Rutman Lori , Wilkes Jennifer , Stimpson Megan , Masse Elizabeth , Barry Dwight , Roberts Joan 
Published: June 2019

Introduction:
Pediatric oncology patients are a high-risk population for septic shock. These patients often screen positive for sepsis during hospitalization, making it difficult to discern when care escalations are warranted. This poses challenges to timely clinical decision-making, which can result in extended periods of hypotension and increased risk for clinical deterioration. The aim of this project was to decrease the frequency of “rescue events” (hypotension for 2 hours before initiation of vasoactive medications) in pediatric oncology patients by 25% within 6 months of implementing standardized hypotension [mean arterial pressure (MAP)] thresholds on a septic shock pathway.

Methods:
A key driver diagram was developed (Fig. 1). Age-based MAP norms were integrated into the electronic medical record. Critical MAP thresholds for provider evaluation were included in a revised septic shock pathway. Rescue events were measured over time.

Results:
The revised septic shock pathway was implemented in December 2016. Baseline data from 10/1/15 to 12/30/16 showed 10 rescue events (0.7 events per 1,000 patient days), with reduction to 2 rescue events from 1/1/17 to 6/30/17 (0.3 events per 1,000 patient days). This represents a 60% reduction in events, and 56% reduction in the rate of events. The distribution of days between rescue events shifted considerably after implementation (Fig. 2); median days between events increased from 16 days (interquartile range, 7–22) to 37 days (interquartile range, 27–56).

Conclusion:
Integration of simple, actionable blood pressure thresholds in a standardized pathway for sepsis led to a reduction of preventable harm (rescue events) among pediatric oncology patients.
Implementing a Standardized Clinical Pathway Leads to Reduced Asthma Admissions and Health Care Costs
Authors: McCoy Elisha M. , Kink Rudy J. , Harrold La Precious L. , Longjohn Mindy K. , Meredith Mark L. , Pishko Stephen D. 
Published: June 2019

Introduction:
Asthma exacerbations are 1 of the leading causes of hospital admissions in children in the United States. High volumes in the emergency department can lead to delayed treatment. Several studies have shown that implementation of a standardized clinical pathway can improve adherence to evidence-based standards. The purpose of our quality improvement project was to develop a standardized pathway of care for children with asthma exacerbations to improve time to treatment and reduce admissions.

Methods:
The team used process mapping to review the current process of care for patients with asthma exacerbations presenting to the Emergency Department. After identification of several barriers, the team used plan-do-study-act cycles to develop a standardized clinical pathway of care for children based on their respiratory clinical score. Further interventions occurred after data collection and analyzation through run charts.

Results:
Implementation of a standardized clinical pathway for children with asthma presenting to the Emergency Department resulted in treatment with steroids in less than 60 minutes. Overall admissions were decreased from an average of 24% to 17% throughout the intervention period. We estimated cost savings for the institution at over $230,000 for the 2 years after implementation of the pathway.

Conclusions:
Using a multidisciplinary team approach to develop a standardized clinical pathway for a common childhood illness like asthma can result in reduced time to treatment and admissions.