Bronchiolitis hospitalizations in rural New England: clues to disease prevention

Background:

An improved understanding of the clinico-epidemiology of bronchiolitis hospitalizations, a clinical surrogate of respiratory syncytial virus (RSV) disease, is critical to inform public health strategies for mitigating the in-patient burden of bronchiolitis in early life.

Methods:

A retrospective chart review was conducted of all bronchiolitis first admissions (N = 295) to the Children’s Hospital at Dartmouth-Hitchcock, CHaD, between 1 November 2010 and 31 October 2017 using the relevant International Classification of Diseases (ICD)-9 and ICD-10 codes for this illness. Abstracted data included laboratory confirmation of RSV infection, severity of illness, duration of hospitalization, age at admission in days, weight at admission, prematurity, siblings, and relevant medical pre-existing conditions.

Results:

Admissions for bronchiolitis were strongly associated with age of the child, the calendar month of an infant’s birth, and the presence of older children in the family. Medical risk factors associated with admission included premature birth and underlying cardiopulmonary disease.

Conclusion:

The very early age of hospitalization emphasizes the high penetration of RSV in the community, by implication the limited protection afforded by maternal antibody, and the complexity of protecting infants from this infection.

Plain Language Summary

Although risks for respiratory syncytial virus (RSV)/bronchiolitis hospitalization are well described, few studies have examined, with precision, the age-related frequency and severity of RSV/bronchiolitis. We also explore the implications of RSV clinico-epidemiology for our understanding of the pathogenesis of the disease and development of optimal approaches to prevention.

Capacity Building for a New Multicenter Network Within the ECHO IDeA States Pediatric Clinical Trials Network

Introduction: Research capacity building is a critical component of professional development for pediatrician scientists, yet this process has been elusive in the literature. The ECHO IDeA States Pediatric Clinical Trials Network (ISPCTN) seeks to implement pediatric trials across medically underserved and rural populations. A key component of achieving this objective is building pediatric research capacity, including enhancement of infrastructure and faculty development. This article presents findings from a site assessment inventory completed during the initial year of the ISPCTN. Methods: An assessment inventory was developed for surveying ISPCTN sites. The inventory captured site-level activities designed to increase clinical trial research capacity for pediatrician scientists and team members. The inventory findings were utilized by the ISPCTN Data Coordinating and Operations Center to construct training modules covering 3 broad domains: Faculty/coordinator development; Infrastructure; Trials/Research concept development. Results: Key lessons learned reveal substantial participation in the training modules, the importance of an inventory to guide the development of trainings, and recognizing local barriers to clinical trials research. Conclusions: Research networks that seek to implement successfully completed trials need to build capacity across and within the sites engaged. Our findings indicate that building research capacity is a multi-faceted endeavor, but likely necessary for sustainability of a unique network addressing high impact pediatric health problems. The ISPCTN emphasis on building and enhancing site capacity, including pediatrician scientists and team members, is critical to successful trial implementation/completion and the production of findings that enhance the lives of children and families.

IDeA States Pediatric Clinical Trials Network for Underserved and Rural Communities

The National Institutes of Health's Environmental Influences on Child Health Outcomes (ECHO) program aims to study high-priority and high-impact pediatric conditions. This broad-based health initiative is unique in the National Institutes of Health research portfolio and involves 2 research components: (1) a large group of established centers with pediatric cohorts combining data to support longitudinal studies (ECHO cohorts) and (2) pediatric trials program for institutions within Institutional Development Awards states, known as the ECHO Institutional Development Awards States Pediatric Clinical Trials Network (ISPCTN). In the current presentation, we provide a broad overview of the ISPCTN and, particularly, its importance in enhancing clinical trials capabilities of pediatrician scientists through the support of research infrastructure, while at the same time implementing clinical trials that inform future health care for children. The ISPCTN research mission is aligned with the health priority conditions emphasized in the ECHO program, with a commitment to bringing state-of-the-science trials to children residing in underserved and rural communities. ISPCTN site infrastructure is critical to successful trial implementation and includes research training for pediatric faculty and coordinators. Network sites exist in settings that have historically had limited National Institutes of Health funding success and lacked pediatric research infrastructure, with the initial funding directed to considerable efforts in professional development, implementation of regulatory procedures, and engagement of communities and families. The Network has made considerable headway with these objectives, opening two large research studies during its initial 18 months as well as producing findings that serve as markers of success that will optimize sustainability.

Team Science Process Builds Research Coordinators' Voices in a National Pediatric Clinical Trials Network

Geographically-dispersed teams have become the norm in clinical research collaborations. The Institutional Development Awards (IDeA) Program, first authorized by Congress in 1993 and managed by the National Institute of General Medical Sciences, has been developed for the purpose of broadening the geographic distribution of National Institutes of Health (NIH) funding for biomedical and behavioral research by enhancing the competitiveness for research funding of institutions located in states in which the aggregate success rate for grant applications to the NIH has historically been low. The IDeA States are composed of the Commonwealth of Puerto Rico and the following 23 states: Alaska, Arkansas, Delaware, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, South Carolina, South Dakota, Vermont, West Virginia, Wyoming. The Environmental influences on Child Health Outcomes (ECHO) research program's IDeA States Pediatric Clinical Trials Network (ISPCTN) was formed in 2016 with 24 sites within the IDeA states to provide clinical trial access to children in rural and underserved communities while building research capacity and infrastructure. In order to become effective, the network research coordinators used many methods to become more cohesive and productive. One of those methods was the use of Team Science.

Training as an Intervention to Decrease Medical Record Abstraction Errors Multicenter Studies

Studies often rely on medical record abstraction as a major source of data. However, data quality from medical record abstraction has long been questioned. Electronic Health Records (EHRs) potentially add variability to the abstraction process due to the complexity of navigating and locating study data within these systems. We report training for and initial quality assessment of medical record abstraction for a clinical study conducted by the IDeA States Pediatric Clinical Trials Network (ISPCTN) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) using medical record abstraction as the primary data source. As part of overall quality assurance, study-specific training for medical record abstractors was developed and deployed during study start-up. The training consisted of a didactic session with an example case abstraction and an independent abstraction of two standardized cases. Sixty-nine site abstractors from thirty sites were trained. The training was designed to achieve an error rate for each abstractor of no greater than 4.93% with a mean of 2.53%, at study initiation. Twenty-three percent of the trainees exceeded the acceptance limit on one or both of the training test cases, supporting the need for such training. We describe lessons learned in the design and operationalization of the study-specific, medical record abstraction training program.

Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost

BACKGROUND AND OBJECTIVE

The incidence and associated costs of neonatal abstinence syndrome (NAS) have recently risen sharply; newborns with NAS occupy 4% of NICU beds. We implemented a coordinated program for NAS including standardized protocols for scoring, medications and weaning, and a calm rooming-in environment, to improve family-centered care and to decrease both length of stay (LOS) and hospital costs.

METHODS

In early 2013, a multidisciplinary quality improvement team began consecutive plan-do-study-act (PDSA) cycles. We trained nurses in modified Finnegan scoring, ensured scoring only after on-demand feeds during skin-to-skin care, and standardized physician score interpretation. We provided prenatal family education, increased family involvement in symptom monitoring and nonpharmacologic treatment, and treated otherwise healthy infants on the inpatient pediatric unit instead of in the NICU. We measured outcomes using statistical process control methods.

RESULTS

At baseline, 46% of inborn infants at-risk for NAS were treated with morphine; by 2015, this decreased to 27%. Adjunctive use of phenobarbital decreased from 13% to 2% in the same period. Average LOS for morphine-treated newborns decreased from 16.9 to 12.3 days, average hospital costs per treated infant decreased from $19 737 to $8755, and costs per at-risk infant dropped from $11 000 to $5300. Cumulative morphine dose decreased from 13.7 to 6.6 mg per treated newborn. There were no adverse events, and 30-day readmission rates remained stable.

CONCLUSIONS

A coordinated, standardized NAS program safely reduced pharmacologic therapy, LOS, and hospital costs. Rooming-in with family and decreased use of NICU beds were central to achieved outcomes.

Family Presence During Pediatric Tracheal Intubations

IMPORTANCE

Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated.

OBJECTIVE

To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs.

EXPOSURES

Family presence and no FP during TI in the PICU.

MAIN OUTCOMES AND MEASURES

The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level.

RESULTS

A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders.

CONCLUSIONS AND RELEVANCE

Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.

Biomarkers and genetics of brain injury risk in diabetic ketoacidosis: A pilot study

Diabetic ketoacidosis (DKA) is the primary cause of death for children with diabetes, especially when complicated by cerebral edema. Central nervous system (CNS) involvement is common, however the mechanism of, and predictors of CNS dysfunction/injury are largely unknown. In this observational pilot study, blood was collected from pediatric DKA patients at three time points (consent, 12 hr and 24 hr after beginning treatment), to test genetic markers, ribonucleic acid expression and plasma biomarkers reflecting inflammation (tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and cerebral dysfunction and/or possible injury (S100β, glial fibrillary acidic protein [GFAP]). Thirty patients were enrolled in the study. The average age was 11.3 yr, 73% were new onset diabetes and 53% were female. Forty percent exhibited abnormal mentation (Glasgow Coma Scale <15), consistent with CNS dysfunction. IL-6 and TNF-α were elevated in plasma, suggesting systemic inflammation. GFAP was measurable in 45% of patients and correlated positively with GCS. Only two patients had detectable levels of S100β. In conclusion, children with DKA often present with evidence of acute neurologic dysfunction or injury. We have demonstrated the feasibility of exploring genetic and biochemical markers of potential importance in the pathophysiology of CNS dysfunction and/or possible injury in DKA. We have identified IL-6, TNF-α and GFAP as potentially important markers for further exploration. A larger, follow-up study will help to better understand the extent and type of CNS injury in DKA as well as the mechanism underlying this dysfunction/injury.

Insulin and dextrose effects on fixed-interval behavioral thermoregulation in albino rats

This study is a systematic replication of the effects of insulin doses on operant behavior reinforced (in an earlier study) by fixed-ratio schedules of microwave (MW) reinforcement. In this study, insulin and dextrose doses were administered (ip) prior to fixed-interval 2-min. schedules of MW reinforcement in rats tested in a cold environment. Six Sprague-Dawley rats were conditioned to regulate their thermal environment with 5-sec. exposures of MW radiation (SAR = 0.34 Watts/kg/(mW/cm2) under the FI-2' schedules. Humulin-regular insulin and 50% solutions of dextrose were administered (ip) alternately with saline control sessions for 8-hr. durations. A within-subjects, repeated-measures 4 x 8 x 3 factorial analysis of variance design showed that insulin doses suppressed operant responding for heat, which confirmed the results of the earlier study under a different schedule. In addition, high doses of dextrose had similar suppressing effects on operant responding for heat. The data are interpreted in terms of the discriminative properties of increased thermogenesis produced by the insulin and dextrose doses. The suppressing effects were more pronounced for the first two hours, yet they persisted for approximately six hours of the 8-hr. sessions.

Handwashing and antiseptic-containing soaps in hospital

Two aspects of handwashing in hospital were considered. A study was carried out to examine the contamination of bar soap and containers, and the use of antiseptic soaps in reducing the resident flora of the skin. Swabs were collected from soap dishes on six wards and from a bacteriology laboratory on four consecutive days. The unmedicated bar soap was replaced by bar soap containing 2.5% povidone-iodine, and further swabs were collected over a period of seven days. Ninety-two isolates from 48 samples were obtained when unmedicated bar soap was used, and nine isolates from 42 samples when povidone-iodine (Betadine) soap was substituted. The number of organisms recovered when povidone-iodine soap was used was much reduced, and Pseudomonas spp were recovered in low numbers on only one occasion. Six laboratory workers took part in a study to compare bar soap with other agents-povidone-iodine soap, povidone-iodine surgical scrub, povidone-iodine alcoholic solution, chlorhexidine surgical scrub, and alcoholic chlorhexidine. Samples were collected after standard washes and after surgical gloves had been worn for 90 minutes. The effect of multiple washes was assessed by samples collected after six washes with the agent under study (three per day) followed by 90 minutes wearing surgical gloves. The average percentage reduction in normal flora obtained indicated that alcoholic chlorhexidine was superior to the other agents.