bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

AbstractEnvironmental 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.
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.