Academic Half Day Improves Resident Perception of Education Without Compromising Patient Safety

BACKGROUND

Residency programs are required to offer a didactic curriculum and protect resident time for education. Our institution implemented an academic half day (AHD) in the 2021-2022 academic year to address issues related to the standard noon conference series.

OBJECTIVE

Determine the impact of AHD implementation on education, patient safety, and workflow.

METHODS

This was a prospective, single-site educational intervention study. Pre- and post-implementation surveys and Accreditation Council for Graduate Medical Education (ACGME) surveys assessed changes in trainee and faculty attitudes and behaviors. Patient safety and workflow were evaluated by comparing the number of safety event reports, rapid response team activations, time to admission from the ED, and time of discharge on AHD days compared to other weekdays.

RESULTS

Survey response rates were: residents 68%/48%, fellows 42%/35%, and faculty 59%/29%. AHD was associated with a significant, positive change in resident attitudes and experiences and on ACGME survey items. On AHDs compared with other weekdays, there were no significant differences in safety event report rates (P = .98), nor in rapid response team activation rates (P = .99). There was not a clinically meaningful difference in median admission time from the ED on AHD weekdays (125 minutes) compared to other weekdays (130 minutes, P = .04). There was no significant difference in median discharge time on AHD vs other weekdays (P = .13).

CONCLUSIONS

This study suggests that there is no significant difference in patient safety or workflow with the implementation of AHD. This study supports prior studies that residents strongly prefer AHD. AHD may be a useful framework for resident education without compromising patient care.

Caregiver Perspectives on Social Needs Screening and Interventions in an Urban Children's Hospital

OBJECTIVES

Caregiver opinions of inpatient social needs screening and ways of addressing positive screens are not well understood. We aimed to explore caregiver perspectives and goals surrounding inpatient screening and determine how helpful provided resources are at meeting these goals.

METHODS

We conducted a qualitative study using semistructured interviews with caregivers of pediatric patients admitted to an urban tertiary care children's hospital from April to August 2021. English- and Spanish-speaking caregivers who screened positive for at least 1 social need on a standardized 10-item questionnaire were invited to participate in an interview 2 to 4 months after discharge. Interviews were recorded, transcribed, and analyzed by 2 independent coders using rapid qualitative methods.

RESULTS

We completed 20 interviews, with 14 English-speaking and 6 Spanish-speaking caregivers. Four themes emerged: (1) All caregivers expressed support for inpatient social needs screening. (2) Many caregivers cited it as an effective means to support families and help providers better understand their social situation. (3) Caregivers who recalled receiving a resource packet found it useful and at times even shared the resources with others. (4) The majority of caregivers expressed interest in longitudinal support, such as contact after discharge.

CONCLUSIONS

Caregivers are in support of inpatient screening as a means for providers to optimize comprehensive care that explores how unmet social needs influence health. Although inpatient social work and resource packets may be helpful, longitudinal support after discharge may improve the effectiveness of social needs interventions, patient outcomes, and caregiver satisfaction.

Factors Associated With Hospitalization in Children and Adolescents With SARS-CoV-2 Infection

In this retrospective study of 319 children with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we assessed whether age, asthma, obesity, diabetes, and socioeconomic status were associated with hospitalization for coronavirus disease 2019 (COVID-19). Demographic and clinical characteristics were assessed using univariate statistics, excluding incidental or unrelated positives. There was a bimodal distribution of age among hospitalized children. Obesity (P < .001) and a past medical history of diabetes (P = .001) were significantly more prevalent in hospitalized children, including cases of new-onset diabetes and diabetic ketoacidosis. Neither a past medical history of asthma nor lower socioeconomic status was associated with hospitalization. Although limited to a single center, the findings in this study may have important clinical implications. Targeted, proactive health outreach to children with obesity and diabetes, with prioritization of preventative efforts such as vaccination, may be important in preventing worse SARS-CoV-2 infection in this vulnerable group.

Severe Acute Respiratory Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth

OBJECTIVE

To characterize the demographic and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes and identify admission variables predictive of disease severity.

STUDY DESIGN

We conducted a multicenter, retrospective, and prospective study of pediatric patients hospitalized with acute SARS-CoV-2 infections and multisystem inflammatory syndrome in children (MIS-C) at 8 sites in New York, New Jersey, and Connecticut.

RESULTS

We identified 281 hospitalized patients with SARS-CoV-2 infections and divided them into 3 groups based on clinical features. Overall, 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations including gastrointestinal illness or fever. Patients with MIS-C were more likely to identify as non-Hispanic black compared with patients with respiratory disease (35% vs 18%, P = .02). Seven patients (2%) died and 114 (41%) were admitted to the intensive care unit. In multivariable analyses, obesity (OR 3.39, 95% CI 1.26-9.10, P = .02) and hypoxia on admission (OR 4.01; 95% CI 1.14-14.15; P = .03) were predictive of severe respiratory disease. Lower absolute lymphocyte count (OR 8.33 per unit decrease in 109 cells/L, 95% CI 2.32-33.33, P = .001) and greater C-reactive protein (OR 1.06 per unit increase in mg/dL, 95% CI 1.01-1.12, P = .017) were predictive of severe MIS-C. Race/ethnicity or socioeconomic status were not predictive of disease severity.

CONCLUSIONS

We identified variables at the time of hospitalization that may help predict the development of severe SARS-CoV-2 disease manifestations in children and youth. These variables may have implications for future prognostic tools that inform hospital admission and clinical management.

The Impact of Parental Presence on Trainee Education During PICU Rounds: A Brief Report

OBJECTIVES

To determine the impact of parental presence on the number and types of educational questions asked of and by medical trainees during PICU rounds.

METHODS

An investigator joined bedside rounds in a 14-bed medical-surgical PICU on 20 weekdays between December 2016 and June 2017. For each patient, the investigator recorded the time devoted to education. Educational questions were recorded verbatim. Questions were categorized as "teaching" (senior team member to a trainee) or "learning" (trainee to a more senior team member) and by content (eg, physiology, imaging, prognosis). Two blinded investigators independently assigned codes to each educational question; discrepancies were resolved to the satisfaction of both.

RESULTS

Data include 151 patient-specific rounding events, involving 92 patients. At least 1 parent attended the entirety of 59/151 rounding events (39%). There were no significant differences between the duration of education or the number of educational questions asked when parents were present (1 minute; 2 questions) versus absent (2 minutes; 2 questions). When parents were present, 20% questions were learning versus 25% when parents were absent. Zero percent of rounding events included ≥1 question about prognosis when parents were present versus 9% when absent (P = .02). There was no statistically significant difference in the frequency of questions related to complications of management or social factors.

CONCLUSIONS

Parent participation in rounds did not impact the quantity of education during rounds but did impact the type of educational questions asked, specifically restricting the discussion of patient prognosis.

Pediatric Nonalcoholic Fatty Liver Disease in New York City: An Autopsy Study

OBJECTIVE

To assess the prevalence and severity of nonalcoholic liver disease (NAFLD) in children in a diverse population sample in New York City.

STUDY DESIGN

Liver specimens were examined from children 2-19 years old who died of unexpected causes within 48 hours of medical presentation and underwent autopsy in New York City from 2005 to 2010. Records were reviewed for age, sex, weight, height, and race. Two hepatopathologists evaluated each liver specimen to determine pathologic diagnosis.

RESULTS

The final study cohort (n = 582) was 50% black, 33% Hispanic, 12% white, 3% Asian, and 2% other; 36% had a body mass index >85%. There were 26 cases of NAFLD (4.5%) of which 10 had nonalcoholic steatohepatitis (1.7%). There were no cases with severe fibrosis or cirrhosis. One percent (3/290) of black children had NAFLD and none had nonalcoholic steatohepatitis. White and Hispanic children had the highest percentages of NAFLD at 8.3% and 7.9%, respectively. In multiple logistic regression models, we observed that body mass index z-score (P < .001) was associated with NAFLD, and that white (P = .003) and Hispanic (P = .005) children had higher odds of having NAFLD compared with black children.

CONCLUSIONS

This review of liver tissue demonstrates a lower prevalence and severity of NAFLD in black children compared with the general obese pediatric population. Hispanic children did not have a significantly increased rate of NAFLD compared with white children, most likely related to the large proportion of Caribbean Hispanic children in New York City.

Parental opinions regarding an opt-out consent process for inpatient pediatric prospective observational research in the US

OBJECTIVE

To explore parental opinions regarding opt-out consent for inpatient pediatric prospective observational research in the US.

STUDY DESIGN

A series of handouts describing hypothetical observational research studies with opt-out consent were reviewed by parents of hospitalized children. A verbal survey explored parental opinions about the proposed consent process.

RESULTS

A total of 166 parents reviewed the handout and completed the survey. Only 2/166 parents (1.2%) objected to the study described and another 10 (6.0%) cited concern about the privacy of their child's medical information. A total of 157 parents were asked "Is it okay to tell you about this kind of research using this handout?" - 116 (74%) responded positively, 19 (12%) responded negatively, and 21 (13%) made an indeterminate or neutral response. When parents were asked to recommend a specific consent approach for observational research, 86 (52%) chose an opt-in approach, 54 (33%) chose opt-out, and 25 (15%) chose "no consent needed". There were no significant associations between parental preferences and whether the child was admitted to the intensive care unit vs. pediatric ward, and no significant difference found based on type of handout reviewed (generic vs. study-specific).

CONCLUSION

Few parents voiced objection to a hypothetical opt-out consent process for inpatient pediatric prospective observational research. When asked to recommend a specific consent approach, though, approximately half chose an opt-in approach. These data suggest that an opt-out consent process for observational inpatient research is likely to be acceptable to parents, but assessment of an opt-out consent process in a real-world setting is needed.

Characterization of MHC class II-presented peptides generated from an antigen targeted to different endocytic compartments

We evaluated the capacity of the secretory pathway or of different endocytic compartments in B cell lines to generate MHC class II-presented peptides from the antigen ovalbumin (OVA). Sorting signals from the transferrin receptor (TFR), targeted a chimeric OVA fusion protein to early endosomes and led to the generation of 8 of 12 presented peptides. Sorting signals from the lysosome-associated membrane protein 1 (LAMP-1), targeted an OVA fusion protein to lysosomes, and led to the generation of 9 of 12 peptides. In contrast, OVA with only a signal sequence led to the generation of only 2 presented peptides. There were both qualitative and quantitative differences in the generation of peptides from the different fusion proteins, suggesting that multiple distinct compartments are involved in generating different epitopes. One peptide was presented better from the TFR fusion protein, while all others were presented better from the LAMP-1 construct. Twelve peptides were generated from exogenously supplied OVA, including 3 peptides that were not generated from any of the fusion proteins. Since most endogenously synthesized foreign antigens are rarely presented on class II molecules, these studies further suggest a strategy whereby antigens in DNA-based vaccines could be targeted to endocytic compartments to enhance immunogenicity.

A monoclonal antibody reactive with a 40-kDa molecule on fetal thymocytes and tumor cells blocks proliferation and stimulates aggregation and apoptosis

E710.2.3 is a murine thymic lymphoma cell line with an immature phenotype (CD4-CD8-) that proliferates in response to thymocytes or PMA when cultured at low density and proliferates spontaneously when grown at high density. To identify functional molecules on this cell line, we screened for mAbs that could block its proliferation. A hamster mAb, DMF10.62.3, inhibited the spontaneous, thymocyte-induced, and PMA-stimulated proliferation of E710.2.3 in vitro and induced these cells to undergo apoptosis. The mAb also caused homotypic aggregation of E710.2.3, which was inhibited by cytochalasin B, trifluoperazine, a combination of sodium azide and 2-deoxyglucose, EDTA, incubation at 4 degrees C, or treatment with paraformaldehyde. The DMF10 62.3 mAb stained a number of immortalized murine and human cell lines and, where tested, blocked their proliferation and caused death to varying extents by apoptosis. The molecule recognized by the mAb DMF10.62.3 was expressed on day 14 fetal thymus Thy1.2-positive cells. However, it was not detected on adult murine thymocytes, splenocytes, or bone marrow cells or on splenic LPS-activated B cells or Con A-activated T cells. The Ab immunoprecipitated a 40-kDa molecule from E710.2.3 that was not glycosylphosphatidylinositol linked. The data suggest that the molecule recognized by DMF62.3 is a novel cell surface molecule that may be involved in cell proliferation and/or cell death.

Comparison of T cell cytokines in resistant and susceptible mice infected with virulent Brucella abortus strain 2308

C57BL/10 and BALB/c mice differ in their abilities to clear infections with the intracellular bacterium Brucella abortus strain 2308. We have previously reported that in vivo of IL-10 in the susceptible BALB/c mice results in significantly fewer bacteria in their spleens 1 week after infection with 5 x 10(3) colony forming units (CFU) of 2308. Here we extend those studies and report a similar effect when IL-4 is neutralized. In contrast, in the more resistant C57BL/10 mice infected with 5 x 10(3) CFU, neither neutralization of IL-4 significantly decreased the level of infection nor did it in either BALB/c or C57BL/10 mice infected with a 1000-fold higher dose of strain 2308. While splenocytes from the later mentioned groups of mice produced IL-10 in response to stimulation with brucella antigen, they also produced higher levels of interferon (IFN)-gamma than those from BALB/c mice with the low challenge dose of 5 x 10(3) CFU. Results of in vivo neutralization of IFN-gamma by monoclonal antibodies (MAb) reported here and elsewhere indicated that IFN-gamma is important for control; thus, we postulate that the higher levels of IFN-gamma override the detrimental effects of Th2 cytokines. In vitro studies also showed that macrophages from the more resistant C57BL/10 mice were less susceptible to the ability of IL-10 to decrease anti-brucella activities than were BALB/c macrophages. CD4+ T cells were principally responsible for the production of IL-10 in BALB/c but not C57BL/10 splenocyte populations. C57BL/10 splenocytes produced more IFN-gamma than those from BALB/c mice in response to stimulation with brucella antigens. These differences between BALB/c and C57BL/10 mice may contribute to the superior capacity of C57BL/10 mice to control infections with B. abortus strain 2308.

Lack of a role for natural killer cells in early control of Brucella abortus 2308 infections in mice

Studies were conducted to determine if natural killer (NK) cells are important for early control of the virulent strain Brucella abortus 2308 following infection of mice with high or low challenge doses. Splenocytes from C57BL/10 and BALB/c mice that had been infected with the lower dose of B. abortus displayed increased cytotoxicity against YAC-1 cells during the first week after infection, while infection of C57BL/10 mice with the higher challenge dose either did not alter the level of NK cytotoxic activity or decreased it, depending upon the time postinfection. In vivo depletion of NK cells by monoclonal antibody anti-NK1.1 or polyclonal anti-asialoGM1 antiserum did not result in an increase in the number of brucellae recovered from the spleens or livers of the brucella-resistant C57BL/10 mice or from the spleens of the susceptible BALB/c mice during the first week after infection. Treatment of control mice with the NK-reactive antibodies, however, decreased killing of the NK-sensitive target YAC-1, indicating that the NK cell depletion regimes were effective. Our results suggest that NK cells are not crucial for early control of B. abortus 2308 even though they may be activated following infection. Further experiments indicated that treatment of C57BL/10 mice with poly(A:U) did not decrease the number of brucellae recovered from their spleens although it did decrease the CFU in livers of mice infected with the high challenge dose.

Interleukin-10 downregulates protective immunity to Brucella abortus

In vivo neutralization of interleukin-10 (IL-10) with an anti-IL-10 monoclonal antibody resulted in up to 10-fold fewer bacteria in the spleens of BALB/c mice infected with the virulent Brucella abortus strain 2308. In vitro neutralization of endogenous IL-10 in brucella antigen-stimulated cultures of splenocytes from infected mice resulted in increased gamma interferon production in these cultures, whereas exogenous recombinant IL-10 inhibited the ability of peptone-elicited peritoneal macrophages to control intracellular brucellae. These data suggest that IL-10 may be downregulating the immune response to B. abortus by affecting both macrophage effector function and the production of the protective Th1 cytokine gamma interferon.

Macrophage control of Brucella abortus: influence of cytokines and iron

Brucella abortus is a facultative intracellular bacterium that can infect and replicate in mononuclear phagocytes. Recent work has elucidated the role of cytokines in activating macrophages to inhibit the intracellular replication of brucellae, and in recruiting macrophages to the site of infection in vivo. There is also evidence that iron increases the ability of cytokine-activated macrophages to control intracellular brucellae by mechanisms involving reactive oxygen intermediates.