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Odegard MN, Ourshalimian SA, Chen SY, Russell CJ, Obinelo AU, Kaplan CM, Kelley-Quon LI. The impact of COVID-19 on racial and ethnic disparities in presentation with perforated appendicitis in children: A retrospective cohort study. Surg Open Sci 2024; 18:53-60. [PMID: 38322023 PMCID: PMC10844646 DOI: 10.1016/j.sopen.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 02/08/2024] Open
Abstract
Background Children from racial and ethnic minority groups have higher prevalence of perforated appendicitis, and the COVID-19 pandemic worsened racial and ethnic health-related disparities. We hypothesized that the incidence of perforated appendicitis worsened for children from racial and ethnic minorities during the COVID-19 pandemic. Methods We performed a retrospective cohort study of the Pediatric Health Information System for children ages 2-18y undergoing appendectomy pre-pandemic (3/19/2019-3/18/2020) and intra-pandemic (3/19/2020-3/30/2021). The primary outcome was presentation with perforated appendicitis. Multivariable logistic regression with mixed effects estimated the likelihood of presentation with perforated appendicitis. Covariates included race, ethnicity, pandemic status, Child Opportunity Index, gender, insurance, age, and hospital region. Results Overall, 33,727 children underwent appendectomy: 16,048 (47.6 %) were Non-Hispanic White, 12,709 (37.7 %) were Hispanic, 2261 (6.7 %) were Non-Hispanic Black, 960 (2.8 %) were Asian, and 1749 (5.2 %) Other. Overall perforated appendicitis rates were unchanged during the pandemic (37.4 % intra-pandemic, 36.4 % pre-pandemic, p = 0.06). Hispanic children were more likely to present with perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.18, 95%CI: 1.07, 1.13). Hispanic children had higher odds of perforated appendicitis versus Non-Hispanic White children pre-pandemic (OR 1.10, 95%CI: 1.00, 1.20) which increased intra-pandemic (OR 1.19, 95%CI: 1.09, 1.30). Publicly-insured children had increased odds of perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.14, 95%CI: 1.03, 1.25), and had increased odds of perforated appendicitis versus privately-insured children (intra-pandemic OR 1.26, 95%CI: 1.16, 1.36; pre-pandemic OR 1.12, 95%CI: 1.04, 1.22). Conclusions During the COVID-19 pandemic, Hispanic and publicly-insured children were more likely to present with perforated appendicitis, suggesting that the pandemic exacerbated existing disparities in healthcare for children with appendicitis. Key message We found that Hispanic children and children with public insurance were more likely to present with perforated appendicitis during the COVID-19 pandemic. Public health efforts aimed at ameliorating racial and ethnic disparities created during the COVID-19 pandemic should consider increasing healthcare access for Hispanic children to address bias, racism, and systemic barriers that may prevent families from seeking care.
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Affiliation(s)
- Marjorie N. Odegard
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | | | - Stephanie Y. Chen
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | | | - Adaeze U. Obinelo
- University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Cameron M. Kaplan
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Keck School of Medicine, 2020 Zonal Avenue, Los Angeles, CA 90033, USA
| | - Lorraine I. Kelley-Quon
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
- Department of Population and Public Health Sciences, University of Southern California, 2001 N. Soto Street, Los Angeles, CA 90032, USA
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Orr CJ, Leslie LK, Schaechter J, Williams XJ, Montez KG, Deen JF, Evans YN, Russell CJ, Webb J, Gaona AR, Mendoza FS. Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce. Pediatrics 2024; 153:e2023063678S. [PMID: 38300010 PMCID: PMC10852199 DOI: 10.1542/peds.2023-063678s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.
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Affiliation(s)
- Colin J. Orr
- Department of Pediatrics
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Kimberly G. Montez
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Jason F. Deen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Yolanda N. Evans
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | - Jonathan Webb
- American Board of Pediatrics, Chapel Hill, North Carolina
- Association of Women’s Health Obstetric and Neonatal Nurses, Washington, District of Columbia
| | | | - Fernando S. Mendoza
- Department of Pediatrics, Stanford School of Medicine, Palo Alto, California
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Steuart R, Pan AY, Woolums A, Benscoter D, Russell CJ, Henningfeld J, Thomson J. Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies. Pediatr Pulmonol 2024; 59:300-313. [PMID: 37937895 DOI: 10.1002/ppul.26746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/22/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown. OBJECTIVE To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies. METHODS This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering. RESULTS Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability. CONCLUSION Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.
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Affiliation(s)
- Rebecca Steuart
- Section of Special Needs, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Henningfeld
- Department of Pediatrics, Section of Pulmonary Medicine, Milwaukee, Wisconsin, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Lascano D, Zamora AK, Mahdi E, Ourshalimian S, Russell CJ, Kim E, Kelley-Quon LI. Gabapentin is Associated With Decreased Postoperative Opioid Use and Length of Stay After Appendectomy in Children With Perforated Appendicitis: A Propensity Score-Matched Analysis. J Pediatr Surg 2023; 58:1935-1941. [PMID: 37029026 PMCID: PMC10771856 DOI: 10.1016/j.jpedsurg.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Gabapentin is increasingly used as an off-label, opioid-sparing pain medication in children. We investigated perioperative gabapentin administration and postoperative opioid use in children who underwent appendectomy for perforated appendicitis. METHODS A retrospective cohort study of healthy children ages 2-18 years undergoing appendectomy for perforated appendicitis from 2014 to 2019 was performed using the Pediatric Health Information System®. Propensity score matched (PSM) analysis was conducted with 1:1 matching based on patient and hospital characteristics. Multivariable linear regression analysis was used to evaluate an association between gabapentin, postoperative opioid use, and postoperative length of stay. RESULTS Of 29,467 children with perforated appendicitis who underwent appendectomy, 236 (0.8%) received gabapentin. In 2014, <10 children received gabapentin, but by 2019, 110 children received gabapentin. On univariate analysis of the PSM cohort, children receiving gabapentin had decreased total postoperative opiate use (2.3 SD ± 2.3 versus 3.0 SD ± 2.5 days, p < 0.001). On adjusted analysis, children receiving gabapentin had 0.65 fewer days of postoperative total opioid use (95% CI: -1.09, -0.21) and spent 0.69 fewer days in the hospital after surgery (95% CI: -1.30, -0.08). CONCLUSION While overall use is infrequent, gabapentin is increasingly administered to children with perforated appendicitis who undergo an appendectomy and is associated with decreased postoperative opioid use and reduced postoperative length of stay. Multimodal pain management strategies incorporating gabapentin may reduce postoperative opioid consumption, but further studies of drug safety are needed for this off-label use in children undergoing surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Abigail K Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA.
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Steuart R, Ale GB, Woolums A, Xia N, Benscoter D, Russell CJ, Shah SS, Thomson J. Respiratory culture organism isolation and test characteristics in children with tracheostomies with and without acute respiratory infection. Pediatr Pulmonol 2023; 58:1481-1491. [PMID: 36751142 DOI: 10.1002/ppul.26349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/05/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Among children with tracheostomies, little is known about how respiratory culture results differ between states with and without acute respiratory infections (ARI), or the overall test performance of respiratory cultures. OBJECTIVE To determine the association of respiratory culture organism isolation with diagnosis of ARI in children with tracheostomies, and assess test characteristics of respiratory cultures in the diagnosis of bacterial ARI (bARI). METHODS This single-center, retrospective cohort study included respiratory cultures of children with tracheostomies obtained between 2010 and 2018. The primary predictor was ARI diagnosis code at the time of culture; the primary outcomes were respiratory culture organism isolation and species identified. Generalized estimating equations were used to assess for association between ARI diagnosis and isolation of any organism while controlling for potential confounders and accounting for within-patient clustering. A multinomial logistic regression equation assessed for association with specific species. Test characteristics were calculated using bARI diagnosis as the reference standard. RESULTS Among 3578 respiratory cultures from 533 children (median 4 cultures/child, interquartile range (IQR): 1-9), 25.9% were obtained during ARI and 17.2% had ≥1 organism. Children with ARI diagnosis had higher odds of organism identification (adjusted odds ratio 1.29, 95% confidence interval [CI] 1.16-1.44). When controlling for covariates, ARI was associated with isolation of Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, and Streptococcus pyogenes. Test characteristics revealed a 24.3% sensitivity, 85.2% specificity, 36.5% positive predictive value, and 76.3% negative predictive value in screening for bARI. CONCLUSION The utility of respiratory culture testing to screen for, diagnose, and direct treatment of ARI in children with tracheostomies is limited.
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Affiliation(s)
- Rebecca Steuart
- Department of Pediatrics, Section of Special Needs, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Guillermo B Ale
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Pulmonary and Sleep Medicine, Children's of Alabama, Birmingham, Alabama, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicole Xia
- Department of Pediatrics, Section of Special Needs, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Samir S Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Smith DF, Brady PW, Russell CJ. Introducing: Health Equity Rounds. Hosp Pediatr 2023; 13:459-460. [PMID: 37066666 DOI: 10.1542/hpeds.2023-007234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Affiliation(s)
- Danielle F Smith
- Cohen Children's Medical Center, New Hyde Park, New York, New York
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California; and
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Chen SY, Ourshalimian S, Kim E, Russell CJ, Kelley-Quon LI. Tramadol Use in Pediatric Surgery: Trends After the Food and Drug Administration Black-Box Warning. J Surg Res 2022; 280:10-18. [PMID: 35944445 DOI: 10.1016/j.jss.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION The U.S. Food and Drug Administration (FDA) issued a black-box warning in 2017 contraindicating tramadol in children <12 y. Longitudinal trends and factors associated with perioperative tramadol use in children remain unclear. METHODS A retrospective, multi-institutional cohort study utilizing the Pediatric Health Information System database was performed for children 2-18 y who underwent one of ten common surgeries from 1/2009-2/2020. Temporal trends correlated with the FDA tramadol contraindication were evaluated. Hierarchical multivariable logistic regression analysis identified factors associated with tramadol use. RESULTS Of 477,153 children undergoing surgery, 5857(1.2%) received tramadol during hospitalization. Tramadol use occurred in 942 (16.1%) children after the black-box warning, 390 of whom were <12 y. For children <12 y, annual tramadol use peaked at 1.87% (2016) and decreased to 0.66% (2019). Female sex (odds ratio OR 1.32; 95% confidence interval CI:1.24,1.40), age ≥12 y (OR 2.79; 95%CI: 2.62,2.97), and Midwest location (OR 4.07; 95% CI:1.64,10.11) increased likelihood of receiving tramadol. Tramadol use was more likely after cholecystectomy (OR 1.17; 95% CI:1.04,1.32) and in children with gastrointestinal (OR 2.39; 95% CI: 2.19,2.60), metabolic (OR 1.39; 95% CI:1.26,1.53) or transplant-related (OR 1.82; 95% CI: 1.57,2.10) comorbidities. Children of Hispanic/Latino ethnicity and those with public insurance had decreased likelihood of receiving tramadol. Adjusting for patient and hospital characteristics, children <12 y were less likely to receive tramadol following the black-box warning (OR 0.65; 95% CI: 0.59,0.70). CONCLUSIONS Despite the FDA contraindication, tramadol prescribing continues among children <12 y undergoing surgery, with use varying by patient and institutional factors. Interventions are required to reduce perioperative tramadol use in children.
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Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California.
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Kingston P, Lascano D, Ourshalimian S, Russell CJ, Kim E, Kelley-Quon LI. Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis. J Pediatr Surg 2022; 57:1487-1493. [PMID: 34893309 PMCID: PMC9133265 DOI: 10.1016/j.jpedsurg.2021.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ketorolac is an opioid sparing agent commonly used in children. However, ketorolac may be avoided in children with peritonitis owing to a possible increased risk of bleeding. METHODS A retrospective cohort study of healthy children 2-18 years who underwent appendectomy for perforated appendicitis was performed using the Pediatric Health Information System (2009-2019). Multivariable logistic regression was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery, adjusting for patient and hospital level factors. An interaction between ketorolac and ibuprofen was evaluated to identify synergistic effects. RESULTS Overall, 55,603 children with perforated appendicitis underwent appendectomy and 82.3% (N = 45,769) received ketorolac. Of those, 32% (N = 14,864) also received ibuprofen. Receipt of a blood transfusion was infrequent (N = 189, 0.3%). On multivariable logistic regression analysis, perioperative ketorolac administration was associated with decreased odds of a blood transfusion (OR 0.53, 95% CI: 0.35-0.79). However, children receiving ketorolac and ibuprofen were more likely to require a blood transfusion (OR 1.99, 95% CI: 1.42-2.79). In a subset of children receiving ketorolac, each additional day of ketorolac was associated with an increase odds of blood transfusion (OR 1.39, 95% CI: 1.30-1.49). CONCLUSION Perioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis. However, use of both ketorolac and ibuprofen during hospitalization was associated with increased risk of bleeding, although precise timing of administration of these medications was unable to be determined. Extended ketorolac use was also associated with increased risk of bleeding requiring blood transfusion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Paige Kingston
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Danny Lascano
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital of Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Eugene Kim
- Children’s Hospital of Los Angeles, Division of Pain Medicine. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States.,Department of Preventive Medicine, University of Southern California. 2001 N Soto St, Los Angeles, CA 90032, United States.,Corresponding Author. Lorraine Kelley-Quon, Assistant Professor of Clinical Surgery and Preventive Medicine, Division of Pediatric Surgery, Children’s Hospital Los Angeles, Department of Surgery and Preventive Medicine, Keck School of Medicine of University of Southern California, 4650 Sunset Blvd. MS #100, Los Angeles, CA 90027, Phone: 323-361-1628, Fax: 323-361-3534, Cell: 323- 397-8539, Twitter Handles: @LKelley_Quon, @HOPE_sci_lab, @ChildrensLA,
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Sochet AA, Morrison JM, Jaffray J, Godiwala N, Wilson HP, Thornburg CD, Bhat RV, Zia A, Lawrence C, Kudchadkar SR, Hamblin F, Russell CJ, Streiff MB, Spyropoulos AC, Amankwah EK, Goldenberg NA. Enoxaparin Thromboprophylaxis in Children Hospitalized for COVID-19: A Phase 2 Trial. Pediatrics 2022; 150:e2022056726. [PMID: 35484817 DOI: 10.1542/peds.2022-056726] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence regarding the safety and efficacy of anticoagulant thromboprophylaxis among pediatric patients hospitalized for coronavirus disease 2019 (COVID-19) is limited. We sought to evaluate safety, dose-finding, and preliminary efficacy of twice-daily enoxaparin as primary thromboprophylaxis among children hospitalized for symptomatic COVID-19, including primary respiratory infection and multisystem inflammatory syndrome in children (MISC). METHODS We performed a phase 2, multicenter, prospective, open-label, single-arm clinical trial of twice-daily enoxaparin (initial dose: 0.5mg/kg per dose; max: 60mg; target anti-Xa activity: 0.20-0.49IU/mL) as primary thromboprophylaxis for children <18 years of age hospitalized for symptomatic COVID-19. Study endpoints included: cumulative incidence of International Society of Thrombosis and Haemostasis-defined clinically relevant bleeding; enoxaparin dose-requirements; and cumulative incidence of venous thromboembolism within 30-days of hospital discharge. Descriptive statistics summarized endpoint estimates that were further evaluated by participant age (±12 years) and clinical presentation. RESULTS Forty children were enrolled and 38 met analyses criteria. None experienced clinically relevant bleeding. Median (interquartile range) dose to achieve target anti-Xa levels was 0.5 mg/kg (0.48-0.54). Dose-requirement did not differ by age (0.5 [0.46-0.52] mg/kg for age ≥12 years versus 0.52 [0.49-0.55] mg/kg for age <12 years, P = .51) but was greater for participants with MISC (0.52 [0.5-0.61] mg/kg) as compared with primary COVID-19 (0.48 [0.39-0.51] mg/kg, P = .010). Two children (5.3%) developed central-venous catheter-related venous thromboembolism. No serious adverse events were related to trial intervention. CONCLUSIONS Among children hospitalized for COVID-19, thromboprophylaxis with twice-daily enoxaparin appears safe and warrants further investigation to assess efficacy.
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Affiliation(s)
| | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nihal Godiwala
- Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Hope P Wilson
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Courtney D Thornburg
- Department of Pediatrics, University of California San Diego, La Jolla, California Division of Hematology and Oncology, Rady Children's Hospital San Diego, San Diego, California
| | - Rukhmi V Bhat
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas Southwestern, Dallas, Texas
| | | | - Sapna R Kudchadkar
- Critical Care Medicine
- Pediatrics
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Christopher J Russell
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Alex C Spyropoulos
- Department of Medicine, Zucker School of Medicine at Hofstra and Northwell and Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ernest K Amankwah
- Departments of Anesthesia
- Pediatrics
- Oncology, Johns Hopkins All Children's Institute for Clinical and Translational Research
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Morrison JM, Hassan A, Kysh L, Dudas RA, Russell CJ. Diagnosis, management, and outcomes of pediatric tracheostomy-associated infections: A scoping review. Pediatr Pulmonol 2022; 57:1145-1156. [PMID: 35229491 PMCID: PMC9313552 DOI: 10.1002/ppul.25873] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/15/2022] [Accepted: 02/27/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Children with tracheostomy are frequently admitted to the hospital for tracheostomy-associated respiratory infections (TRAINs). However, there remains a paucity of evidence to direct the diagnosis, treatment, and prevention of TRAINs. An important first step to addressing this knowledge gap is to synthesize existing data regarding TRAINs to inform current practice and facilitate innovation. DATA SOURCES We searched PubMed, Embase, Cochrane Library, CINAHL, and Web of Science from inception to October 2020. Original research articles and published abstracts including children and young adults 0-21 years of age with tracheostomy were included. Included studies assessed the clinical definitions of and risk factors for TRAINs, microbiologic epidemiology and colonization of tracheostomies, and treatment and outcomes of TRAINs. DATA SYNTHESIS Out of 5755 studies identified in the search, 78 full-text studies were included in the final review. A substantial number of studies focused on the detection of specific pathogens in respiratory cultures including Pseudomonas aeruginosa. Several different definitions of TRAIN including clinical, microbiologic, and laboratory testing results were utilized; however, no uniform set of criteria were identified. The few studies focused on treatment and prevention of TRAIN emphasized the role of empiric antimicrobial therapy and the use of inhaled antibiotics. CONCLUSIONS Despite a growing number of research articles studying TRAINs, there is a paucity of prospective interventional trials to guide the diagnosis, treatment, and prevention of respiratory disease in this vulnerable population. Future research should include studies of interventions designed to improve short- and long-term respiratory-related outcomes of children with tracheostomy.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Amir Hassan
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lynn Kysh
- The Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robert A Dudas
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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11
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Cohen A, Montez K, Orr C, Konrath J, Oddiri U, Russell CJ, Gambill L, Nesiama JA, Chung PJ, McNeal-Trice K. Changing Who Has a Seat and Voice at the Table: How the Academic Pediatric Association is Responding to Systemic Racism. Acad Pediatr 2022; 22:352-355. [PMID: 35032709 DOI: 10.1016/j.acap.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/28/2022]
Abstract
The Academic Pediatrics Association has taken multiple steps over the last 2 years to incorporate the lenses of anti-racism and social justice into our mission and work. In this commentary, we discuss the creation and work of the Anti-Racism and Diversity Task Force, which was charged by the Academic Pediatrics Association's Board of Directors with identifying strategies to promote anti-racism and advance the diversity, equity and inclusion agenda.
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Affiliation(s)
- Adam Cohen
- Division of Hospital Medicine, (Adam Cohen), Baylor College of Medicine and Texas Children's Hospital, Houston, Tex.
| | - Kimberly Montez
- Department of Pediatrics, (Kimberly Montez), Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC
| | - Colin Orr
- Division of General Pediatrics and Adolescent Medicine, (Colin Orr), Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jessica Konrath
- Academic Pediatrics Association, (Jessica Konrath), McLean, Va
| | - Uchechi Oddiri
- Division of Pediatric Critical Care Medicine, (Uchechi Oddiri), Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Christopher J Russell
- Division of Hospital Medicine, (Christopher J. Russell), Children's Hospital Los Angeles, Los Angeles Calif; Department of Pediatrics, (Christopher J. Russell), Keck School of Medicine, University of Southern California, Los Angeles Calif
| | - Lauren Gambill
- Pediatrics University of Texas at Austin Dell Medical School, (Lauren Gambill), Pediatric Hospitalist Dell Children's Medical Center of Central, Austin, Tex
| | - Jo-Ann Nesiama
- Division of Emergency Medicine, (Jo-Ann Nesiama), UT Southwestern Medical Center, Dallas, Tex
| | - Paul J Chung
- Kaiser Permanente Bernard J. Tyson School of Medicine, (Paul J. Chung), Pasadena, CA; University of California Los Angeles, Los Angeles, Calif
| | - Kenya McNeal-Trice
- Department of Pediatrics, (Kenya McNeal-Trice), Division of Hospital Medicine and Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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12
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Xue X, Bian L, Shu J, Yuan Q, Zhu X, Bhat NDR, Dai S, Feng Y, Goncharov B, Hobbs G, Howard E, Manchester RN, Russell CJ, Reardon DJ, Shannon RM, Spiewak R, Thyagarajan N, Wang J. Constraining Cosmological Phase Transitions with the Parkes Pulsar Timing Array. Phys Rev Lett 2021; 127:251303. [PMID: 35029430 DOI: 10.1103/physrevlett.127.251303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/06/2021] [Indexed: 06/14/2023]
Abstract
A cosmological first-order phase transition is expected to produce a stochastic gravitational wave background. If the phase transition temperature is on the MeV scale, the power spectrum of the induced stochastic gravitational waves peaks around nanohertz frequencies, and can thus be probed with high-precision pulsar timing observations. We search for such a stochastic gravitational wave background with the latest data set of the Parkes Pulsar Timing Array. We find no evidence for a Hellings-Downs spatial correlation as expected for a stochastic gravitational wave background. Therefore, we present constraints on first-order phase transition model parameters. Our analysis shows that pulsar timing is particularly sensitive to the low-temperature (T∼1-100 MeV) phase transition with a duration (β/H_{*})^{-1}∼10^{-2}-10^{-1} and therefore can be used to constrain the dark and QCD phase transitions.
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Affiliation(s)
- Xiao Xue
- CAS Key Laboratory of Theoretical Physics, Institute of Theoretical Physics, Chinese Academy of Sciences, Beijing 100190, China
- School of Physical Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
- II. Institute of Theoretical Physics, Universität Hamburg, 22761 Hamburg, Germany
| | - Ligong Bian
- Department of Physics, Chongqing University, Chongqing 401331, China
- Chongqing Key Laboratory for Strongly Coupled Physics, Chongqing 401331, China
| | - Jing Shu
- CAS Key Laboratory of Theoretical Physics, Institute of Theoretical Physics, Chinese Academy of Sciences, Beijing 100190, China
- School of Physical Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
- School of Fundamental Physics and Mathematical Sciences, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Hangzhou 310024, China
- Center for High Energy Physics, Peking University, Beijing 100871, China
- International Center for Theoretical Physics Asia-Pacific, Beijing/Hanzhou, China
| | - Qiang Yuan
- Center for High Energy Physics, Peking University, Beijing 100871, China
- Key Laboratory of Dark Matter and Space Astronomy, Purple Mountain Observatory, Chinese Academy of Sciences, Nanjing 210023, China
- School of Astronomy and Space Science, University of Science and Technology of China, Hefei 230026, China
| | - Xingjiang Zhu
- School of Physics and Astronomy, Monash University, Clayton, VIC 3800, Australia
- OzGrav: The ARC Centre of Excellence for Gravitational Wave Discovery, Hawthorn, VIC 3122, Australia
- Advanced Institute of Natural Sciences, Beijing Normal University at Zhuhai 519087, China
| | - N D Ramesh Bhat
- International Centre for Radio Astronomy Research, Curtin University, Bentley, WA 6102, Australia
| | - Shi Dai
- Western Sydney University, Locked Bag 1797, Penrith South DC, NSW 1797, Australia
| | - Yi Feng
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Boris Goncharov
- School of Physics and Astronomy, Monash University, Clayton, VIC 3800, Australia
- OzGrav: The ARC Centre of Excellence for Gravitational Wave Discovery, Hawthorn, VIC 3122, Australia
| | - George Hobbs
- CSIRO Astronomy and Space Science, P.O. Box 76, Epping, NSW 1710, Australia
| | - Eric Howard
- CSIRO Astronomy and Space Science, P.O. Box 76, Epping, NSW 1710, Australia
- Macquarie University, Department of Physics and Astronomy, Sydney, NSW, 2109, Australia
| | | | - Christopher J Russell
- CSIRO Scientific Computing, Australian Technology Park, Locked Bag 9013, Alexandria, NSW 1435, Australia
| | - Daniel J Reardon
- OzGrav: The ARC Centre of Excellence for Gravitational Wave Discovery, Hawthorn, VIC 3122, Australia
- Centre for Astrophysics and Supercomputing, Swinburne University of Technology, P.O. Box 218, Hawthorn, VIC 3122, Australia
| | - Ryan M Shannon
- OzGrav: The ARC Centre of Excellence for Gravitational Wave Discovery, Hawthorn, VIC 3122, Australia
- Centre for Astrophysics and Supercomputing, Swinburne University of Technology, P.O. Box 218, Hawthorn, VIC 3122, Australia
| | - Renée Spiewak
- Centre for Astrophysics and Supercomputing, Swinburne University of Technology, P.O. Box 218, Hawthorn, VIC 3122, Australia
- Jodrell Bank Centre for Astrophysics, University of Manchester, Manchester M13 9PL, United Kingdom
| | | | - Jingbo Wang
- Xinjiang Astronomical Observatory, Chinese Academy of Sciences, 150 Science 1-Street, Urumqi, Xinjiang 830011, China
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Abstract
OBJECTIVES Many hospitalized children are underimmunized. We assessed the association between hospital immunization practices and tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal, human papillomavirus (HPV), and influenza vaccine delivery. METHODS An electronic survey regarding hospital vaccine delivery practices was distributed via the Pediatric Health Information System (PHIS) and Pediatric Research in Inpatient Settings networks to PHIS hospitals. Number of vaccines delivered and total discharges in 2018 were obtained from the PHIS database to determine hospital vaccine delivery rates; patients 11 to 18 years old (adolescent vaccines) and 6 months to 18 years old (influenza vaccine) were included. Vaccine delivery rates were risk adjusted by using generalized linear mixed-effects modeling and compared with survey responses to determine associations between the number or presence of specific practices and vaccine delivery. Adjusted HPV and meningococcal vaccine delivery rates could not be calculated because of low delivery. RESULTS Twenty-nine hospitals completed a survey (57%). 152 499 and 423 046 patient encounters were included for the adolescent and influenza vaccines, respectively. Unadjusted inpatient vaccine delivery rates varied. After adjustment, the number of practices was associated only with influenza vaccine delivery (P = .02). Visual prompts (P = .02), nurse or pharmacist ordering (P = .003), and quality improvement projects (P = .048) were associated with increased influenza vaccine delivery; nurse or pharmacist ordering had the greatest impact. No practices were associated with Tdap vaccine delivery. CONCLUSIONS The number and presence of specific hospital practices may impact influenza vaccine delivery. Further research is needed to identify strategies to augment inpatient adolescent immunization.
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Affiliation(s)
- Alexandra J Mihalek
- Hospitalist Division, Children's Hospital of Orange County, Orange, California
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Susan Wu
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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14
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Gilliam C, Russell CJ. Impact of racial microaggressions in the clinical learning environment and review of best practices to support learners. Curr Probl Pediatr Adolesc Health Care 2021; 51:101090. [PMID: 34740488 DOI: 10.1016/j.cppeds.2021.101090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Microaggressions are brief, commonplace, and daily verbal, behavioral, and environmental slights towards marginalized groups. Underrepresented in medicine (UiM) learners experience a barrage of microaggressions in the pediatric clinical learning environment. Literature demonstrates that microaggressions are detrimental to the mental and physical well-being of the recipient. There is an urgent need to bring greater awareness and understanding of how microaggressions operate in the clinical learning environment, the impact they have on UiM learners and the educational and institutional strategies needed to best support learners. Several databases were searched using combinations of subject headings and keywords as described. While "microaggressions" is not yet an official medical subject heading (Mesh term) for the National Library of Medicine's databases, nonetheless there are numerous studies using the term microaggressions in the research literature about health care, medical education and learning environments. Items were limited to English language publications from the past 10 years. Microaggressions are rooted in power differentials and indirect assertion of power. The clinical learning environment contains learners at all levels along with patients and families. The impact of microaggressions leads to (1) othering (2) stunted professional identity formation and (3) racial battle fatigue. Both educational initiatives targeted at recognizing and responding to microaggressions and institutional anonymous reporting systems and policies are best practices to combat the negative impact of microaggressions. Institutions-at-large and graduate medical education need to create safe spaces for anonymous reporting, robust policies for addressing bias and educational initiatives for responding to microaggressions. Together these will begin to create safe spaces for our UiM learners in a system that so often perpetuates they do not belong.
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Affiliation(s)
- Courtney Gilliam
- Pediatric Hospital Medicine Fellow, Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, FA.2.115, Seattle, Washington 98105, USA.
| | - Christopher J Russell
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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15
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Schondelmeyer AC, Bettencourt AP, Xiao R, Beidas RS, Wolk CB, Landrigan CP, Brady PW, Brent CR, Parthasarathy P, Kern-Goldberger AS, Sergay N, Lee V, Russell CJ, Prasto J, Zaman S, McQuistion K, Lucey K, Solomon C, Garcia M, Bonafide CP. Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial. JAMA Netw Open 2021; 4:e2122826. [PMID: 34473258 PMCID: PMC8414187 DOI: 10.1001/jamanetworkopen.2021.22826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high. OBJECTIVES To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen. INTERVENTIONS Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits. MAIN OUTCOMES AND MEASURES Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen. RESULTS A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring. CONCLUSIONS AND RELEVANCE In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04178941.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita R. Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Padmavathy Parthasarathy
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nathaniel Sergay
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vivian Lee
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Julianne Prasto
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Pediatrics, Children’s Hospital of Philadelphia Pediatric Care and Penn Medicine Princeton Medical Center, Philadelphia, Pennsylvania
| | - Sarah Zaman
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Kaitlyn McQuistion
- University of Washington Pediatric Residency Program, Department of Pediatrics, University of Washington, Seattle
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
- Division of Pediatric Hospital Medicine, Children’s Health Dallas, Texas
| | - Mayra Garcia
- Division of General and Thoracic Surgery, Children’s Health Dallas, Dallas, Texas
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Abstract
BACKGROUND AND OBJECTIVE Technology-dependent children (TDC) are admitted to both children's hospitals (CHs) and nonchildren's hospitals (NCHs), where there may be fewer pediatric-specific specialists or resources. Our objective was to compare the characteristics of TDC admitted to CHs versus NCHs. METHODS This was a multicenter, retrospective study using the 2012 Kids' Inpatient Database. We included patients aged 0 to 18 years with a tracheostomy, gastrostomy, and/or ventricular shunt. We excluded those who died, were transferred into or out of the hospital, had a length of stay (LOS) that was an extreme outlier, or had missing data for key variables. We compared patient and hospital characteristics across CH versus NCH using χ2 tests and LOS and cost using generalized linear models. RESULTS In the final sample of 64 521 discharges, 55% of discharges of TDC were from NCHs. A larger proportion of those from CHs had higher disease severity (55% vs 49%; P < .001) and a major surgical procedure during hospitalization (28% vs 24%; P < .001). In an adjusted generalized linear model, the mean LOS was 4 days at both hospital types, but discharge from a CH was associated with a higher adjusted mean cost ($16 754 vs $12 023; P < .001). CONCLUSIONS Because the majority of TDC are hospitalized at NCHs, future research on TDC should incorporate NCH settings. Further studies should investigate if some may benefit from regionalization of care or earlier transfer to a CH.
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Affiliation(s)
- Namrata Ahuja
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and .,Departments of Pediatrics and
| | - Wendy J Mack
- Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and.,Departments of Pediatrics and
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17
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Montez K, Omoruyi EA, McNeal-Trice K, Mack WJ, Yemane L, Darden AR, Russell CJ. Trends in Race/Ethnicity of Pediatric Residents and Fellows: 2007-2019. Pediatrics 2021; 148:peds.2020-026666. [PMID: 34131043 PMCID: PMC8290973 DOI: 10.1542/peds.2020-026666] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A diverse pediatric workforce reflecting the racial/ethnic representation of the US population is an important factor in eliminating health inequities. Studies reveal minimal improvements over time in the proportions of underrepresented in medicine (URiM) physicians; however, studies assessing trends in pediatric URiM trainee representation are limited. Our objective was to evaluate longitudinal trends in racial/ethnic representation among a cross-section of US pediatric trainees and to compare it to the US population. METHODS Repeated cross-sectional study of graduate medical education census data on self-reported race/ethnicity of pediatric residents and subspecialty fellows from 2007 to 2019. To evaluate trends in URiM proportions over time, the Cochran-Armitage test was performed. Data on self-reported race/ethnicity of trainees were compared with the general population data over time by using US Census Bureau data. RESULTS Trends in URiM proportions were unchanged in residents (16% in 2007 to 16.5% in 2019; P = .98) and, overall, decreased for fellows (14.2% in 2007 to 13.5% in 2019; P = .002). URiM fellow trends significantly decreased over time in neonatal-perinatal medicine (P < .001), infectious diseases (P < .001), and critical care (P = .006) but significantly increased in endocrinology (P = .002) and pulmonology (P = .009). Over time, the percentage of URiM pediatric trainee representation was considerably lower compared to the US population. CONCLUSIONS The continued underrepresentation of URiM pediatric trainees may perpetuate persistent health inequities for minority pediatric populations. There is a critical need to recruit and retain pediatric URiM residents and subspecialty fellows.
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Affiliation(s)
- Kimberly Montez
- Department of Pediatrics, Wake Forest Baptist Medical Center and Wake Forest University, Winston-Salem, North Carolina
| | - Emma A. Omoruyi
- Department of Pediatrics, John P. and Kathrine G. McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Kenya McNeal-Trice
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Lahia Yemane
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Alissa R. Darden
- Department of Child Health, College of Medicine–Phoenix, University of Arizona, Phoenix, Arizona
| | - Christopher J. Russell
- Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California,Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
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18
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Mahdi EM, Ourshalimian S, Darcy D, Russell CJ, Kelley-Quon LI. The impact of intravenous acetaminophen pricing on opioid utilization and outcomes for children with appendicitis. Surgery 2021; 170:932-938. [PMID: 33985768 DOI: 10.1016/j.surg.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2014, the price of intravenous acetaminophen more than doubled. This study determined whether increased intravenous acetaminophen cost was associated with decreased utilization and increased opioid use for children undergoing appendectomy. METHODS A multicenter retrospective cohort study using the Pediatric Health Information System database between 2011 and 2017 was performed. Healthy children 2 to 18 years undergoing appendectomy at 46 children's hospitals in the United States were identified. Intravenous acetaminophen use, opioid use, and pharmacy costs were assessed. Multivariable mixed-effects modeling was used to determine the association between postoperative opioid use, intravenous acetaminophen use, and postoperative length-of-stay. RESULTS Overall, 110,019 children undergoing appendectomy were identified, with 22.5% (N = 24,777) receiving intravenous acetaminophen. Despite the 2014 price increase, intravenous acetaminophen use increased from 3% in 2011 to 40.1% in 2017 (P < .001), but at a significantly reduced rate. After 2014, adjusted median pharmacy charges decreased from $3,326.5 (interquartile range: $1,717.5-$6,710.8) to $3,264.1 (interquartile range: $1,782.8-$5,934.7, P < .001) for children who received intravenous acetaminophen. In 94,745 children staying ≥1 day after surgery, postoperative opioid use decreased from 73.6% in 2011 to 58.6% in 2017 (P < .001). Use of intravenous acetaminophen alone compared to opioids alone after surgery resulted in similar predicted mean postoperative length-of-stay. CONCLUSION In children undergoing appendectomy, intravenous acetaminophen use continued to rise, but at a slower rate after a price increase. Furthermore, adjusted pharmacy charges were lower for children receiving intravenous acetaminophen, possibly secondary to a concurrent decrease in postoperative opioid use. These findings suggest intravenous acetaminophen may be more broadly used regardless of perceived costs to minimize opioid use after surgery.
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Affiliation(s)
- Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - David Darcy
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Christopher J Russell
- Division of Pediatric Hospital Medicine, Children's Hospital Los Angeles, CA Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Preventive Medicine, University of Southern California, Los Angeles, CA.
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19
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Mihalek AJ, Russell CJ, Hassan A, Yeh MY, Wu S. National Inpatient Immunization Patterns: Variation in Practice and Policy Between Vaccine Types. Hosp Pediatr 2021; 11:462-471. [PMID: 33820809 DOI: 10.1542/hpeds.2020-002634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many hospitalized children are underimmunized, yet little is known about current systems supporting inpatient vaccination. We aim to describe national pediatric inpatient immunization practices and determine if variation exists among adolescent, childhood, and influenza vaccines. METHODS An electronic survey regarding hospital vaccination practices was sent to physician, nurse, and pharmacy leaders via the Pediatric Research in Inpatient Settings Network in spring 2019. Hospitals reported the presence of various practices to support inpatient vaccination stratified by vaccine type: tetanus, diphtheria, and acellular pertussis, meningococcal, human papillomavirus, childhood series, and influenza. One-way analysis of variance testing compared differences in numbers of practices and χ2 tests compared proportions of sites reporting each practice between vaccine types. Qualitative responses were evaluated via content analysis. RESULTS Fifty-one of 103 eligible hospitals completed the survey (50%). Standardized policies existed in 92% of hospitals for influenza, 41% for childhood, and 29% for adolescent vaccines. Hospitals identified an average of 5.1 practices to deliver influenza vaccines, compared with 1.5 for childhood; 0.9 for tetanus, diphtheria, and acellular pertussis; 0.7 for meningococcal; and 0.6 for human papillomavirus vaccines (P < .001). Standardized screening tools, visual prompts, standing orders, nurse- or pharmacy-driven screening or ordering, staff education, and quality improvement projects were reported more often for influenza vaccines than other vaccine types (P < .01 for all comparisons). Common barriers to delivery included communication difficulties, lack of systems optimization, and parent and provider discomfort with inpatient immunization. CONCLUSIONS Existing hospital infrastructure supports influenza vaccine delivery over other vaccine types, potentially creating missed inpatient vaccination opportunities.
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Affiliation(s)
- Alexandra J Mihalek
- Division of Hospital Medicine and .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christopher J Russell
- Division of Hospital Medicine and.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Mei Yu Yeh
- The Saban Research Institute and Southern California Clinical and Translational Science Institute Biostatistics Core, Children's Hospital Los Angeles, Los Angeles, California; and
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20
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McDaniel CE, Russell CJ. Top Articles in Pediatric Hospital Medicine: July 2019 to June 2020. Hosp Pediatr 2020; 10:906-912. [PMID: 32703814 DOI: 10.1542/hpeds.2020-001651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Corrie E McDaniel
- Division of Hospital Medicine, Seattle Children's Hospital and Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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21
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Mahdi EM, Ourshalimian S, Russell CJ, Zamora AK, Kelley-Quon LI. Fewer postoperative opioids are associated with decreased duration of stay for children with perforated appendicitis. Surgery 2020; 168:942-947. [PMID: 32654858 DOI: 10.1016/j.surg.2020.04.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/17/2020] [Accepted: 04/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The impact of postoperative opioid use on outcomes for children with perforated appendicitis is unknown. METHODS A retrospective cohort study was performed using the Pediatric Health Information System database from 2005 to 2015. Children 2 to 18 years with perforated appendicitis who underwent an appendectomy were identified. Postoperative day analgesic use was categorized as nonopioid analgesia alone, opioids (with or without nonopioid analgesia), or no analgesics. The impact of postoperative opioid use on postoperative duration of stay and 30-day readmission was evaluated using multivariable mixed-effects regression analysis. RESULTS Overall, 47,726 children with perforated appendicitis were identified. On postoperative day 1, 17.7% received nonopioid analgesia alone, 77.6% received opioids, and 4.7% received no analgesics. On adjusted analysis, postoperative day 1 opioid use was associated with a 0.75-day (95% confidence interval: 0.54-0.96) increased postoperative duration of stay. Starting opioids after postoperative day 1 was associated with 2.21 days (95% confidence interval: 1.90-2.51) longer postoperative duration of stay. Among children who received opioids on postoperative day 1, continued use of opioids after postoperative day 1 was associated with a 1.88 day (95% confidence interval: 1.77-1.98) longer postoperative duration of stay. Postoperative day 1 opioid use did not significantly affect 30-day readmission. CONCLUSION Early and continued postoperative opioid use is associated with prolonged postoperative duration of stay in children undergoing appendectomy for perforated appendicitis. Minimizing opioid use, even on postoperative day 2, may result in a decreased postoperative duration of stay.
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Affiliation(s)
- Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Christopher J Russell
- Division of Pediatric Hospital Medicine, Children's Hospital Los Angeles; Department of Pediatrics, Keck School of Medicine of the University of Southern California
| | - Abigail K Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Preventive Medicine, University of Southern California, Los Angeles.
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22
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Russell CJ, White AA. Aspiring to Treat Wisely: Challenges in Diagnosing and Optimizing Antibiotic Therapy for Aspiration Pneumonia. J Hosp Med 2020; 15:445-446. [PMID: 32897854 DOI: 10.12788/jhm.3375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/26/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andrew A White
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
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23
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Bochner RE, Kuroki R, Lui K, Russell CJ, Rackovsky E, Piper L, Ban K, Yang K, Mandal P, Mackintosh L, Mirzaian CB, Gross E. Variations in Care for Breastfed Infants Admitted to US Children's Hospitals: A Multicenter Survey of Inpatient Providers. Hosp Pediatr 2019; 10:70-75. [PMID: 31826917 DOI: 10.1542/hpeds.2019-0199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies have revealed an association between hospitalization of breastfed infants and weaning posthospitalization. It is unknown what steps inpatient providers at children's hospitals are currently taking to support breastfeeding mothers of hospitalized infants, their comfort providing breastfeeding counseling, and what training they receive. METHODS We conducted a multicenter survey study of pediatric providers who care for infants hospitalized at 3 urban, tertiary-care children's hospitals over a 12-month period. A convenience sample of nurses, residents, and attending physicians agreed to participate. Participants completed a 24-question questionnaire addressing provider practices, comfort with breastfeeding counseling, and previous breastfeeding education. Data were summarized as medians (interquartile ranges) and frequencies (percentages). Kruskal-Wallis and χ2 tests were used to compare between provider types. RESULTS A total of 361 out of 1097 (33%) eligible providers completed the survey: 133 (21%) nurses, 166 (45%) residents, and 62 (63%) attending physicians. Provider practices varied by provider type. We observed a general trend that providers do not routinely review breastfeeding techniques, directly observe feeds, or use standardized breastfeeding assessment tools. Residents and attending physicians were more likely than nurses to feel comfortable with breastfeeding counseling (P = .02). Residents were more likely than nurses and attending physicians to have received breastfeeding education in the last 3 years (P < .001). CONCLUSIONS Practices, comfort, and previous education varied by provider type. There was a general pattern that providers do not routinely perform certain practices. Further studies are needed to determine if inpatient provider practices affect weaning posthospitalization and if inpatient quality improvement initiatives will help mothers continue breastfeeding posthospitalization.
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Affiliation(s)
- Risa E Bochner
- Department of Pediatrics, University Hospital of Brooklyn, State University of New York Downstate Medical Center and Kings County Hospital Center, Brooklyn, New York;
| | - Robyn Kuroki
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Karen Lui
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Christopher J Russell
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elia Rackovsky
- Department of Pediatrics, Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Laura Piper
- Department of Pediatrics, Cincinnati Children's Hospital and College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Kathryn Ban
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Katharine Yang
- Department of Internal Medicine, Los Angeles County + University of Southern California Medical Center and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Purnima Mandal
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Liza Mackintosh
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christine B Mirzaian
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elissa Gross
- Department of Pediatrics, Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
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24
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Russell CJ, Simon TD, Neely MN. Development of Chronic Pseudomonas aeruginosa-Positive Respiratory Cultures in Children with Tracheostomy. Lung 2019; 197:811-817. [PMID: 31673781 DOI: 10.1007/s00408-019-00285-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Up to 90% of children develop Pseudomonas aeruginosa (Pa)-positive respiratory cultures after tracheotomy. OBJECTIVE To identify the factors associated with chronic Pa-positive respiratory cultures in the first 2 years after tracheotomy. METHODS We conducted a retrospective cohort study of 210 children ≤ 18 years old who underwent tracheotomy at a single freestanding children's hospital that had two or more years of respiratory cultures post-tracheotomy available for analysis. We conducted multivariable logistic regression to test the association between demographic and clinical factors to our primary outcome of chronic Pa infection, defined as > 75% of respiratory cultures positive for Pa in the first 2 years after tracheotomy. RESULTS Of the primarily male (61%), Hispanic (68%), and publicly insured (88%) cohort, 18% (n = 37) developed chronic Pa-positive respiratory cultures in the first 2 years. On multivariable logistic regression, pre-tracheotomy Pa-positive respiratory culture (aOR 11.3; 95% CI 4-1.5) and discharge on beta agonist (aOR 6.3; 95% CI 1.1-36.8) were independently associated with chronic Pa-positive respiratory cultures, while discharge on chronic mechanical ventilation was associated with decreased odds (aOR 0.3; 95% CI 0.1-0.7). On sensitivity analysis examining those without a pre-tracheotomy Pa-positive respiratory culture, discharge on MV continued to be associated with decreased odds of chronic Pa (aOR 0.1; 95% CI 0.02-0.4) and three other variables (male gender, chronic lung disease, and discharge on inhaled corticosteroids) were associated with increased odds of chronic Pa. CONCLUSION Because pre-tracheotomy Pa growth on respiratory culture is associated with post-tracheotomy chronic Pa-positive respiratory cultures, future research should examine pre-tracheotomy Pa eradication or suppression protocols.
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Affiliation(s)
- Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #94, Los Angeles, CA, 90027, USA. .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, WA, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Michael N Neely
- Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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25
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Abstract
OBJECTIVE To investigate the scope of academic spam emails (ASEs) among career development grant awardees and the factors associated with the amount of time spent addressing them. DESIGN A cross-sectional survey of career development grant investigators via an anonymous online survey was conducted. In addition to demographic and professional information, we asked investigators to report the number of ASEs received each day, how they determined whether these emails were spam and time they spent per day addressing them. We used bivariate analysis to assess factors associated with the amount of time spent on ASEs. SETTING An online survey sent via email on three separate occasions between November and December 2016. PARTICIPANTS All National Institutes of Health career development awardees funded in the 2015 fiscal year. MAIN OUTCOME MEASURES Factors associated with the amount of time spent addressing ASEs. RESULTS A total of 3492 surveys were emailed, of which 206 (5.9%) were returned as undeliverable and 96 (2.7%) reported an out-of-office message; our overall response rate was 22.3% (n=733). All respondents reported receiving ASEs, with the majority (54.4%) receiving between 1 and 10 per day and spending between 1 and 10 min each day evaluating them. The amount of time respondents reported spending on ASEs was associated with the number of peer-reviewed journal articles authored (p<0.001), a history of publishing in open access format (p<0.01), the total number of ASEs received (p<0.001) and a feeling of having missed opportunities due to ignoring these emails (p=0.04). CONCLUSIONS ASEs are a common distraction for career development grantees that may impact faculty productivity. There is an urgent need to mitigate this growing problem.
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Affiliation(s)
- Tracey A Wilkinson
- Children's Health Services Research, Indiana University Department of Pediatrics, Indianapolis, Indiana, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - William E Bennett
- Division of Gastroenterology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Erika R Cheng
- Children's Health Services Research, Indiana University Department of Pediatrics, Indianapolis, Indiana, USA
| | - Aaron E Carroll
- Department of Pediatrics, Indiana University, Indianapolis, Indiana, USA
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26
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Miyakawa R, Barreto NB, Kato RM, Neely MN, Russell CJ. Early Use of Anti-influenza Medications in Hospitalized Children With Tracheostomy. Pediatrics 2019; 143:e20182608. [PMID: 30814271 PMCID: PMC6398370 DOI: 10.1542/peds.2018-2608] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Early administration of anti-influenza medications is recommended for all children hospitalized with influenza. We investigated whether early use of anti-influenza medications is associated with improved outcomes in children with tracheostomy hospitalized with influenza. METHODS We performed a multicenter retrospective cohort study through the Pediatric Health Information System database for patients aged 30 days to 19 years who were discharged between October 1, 2007, and September 30, 2015 with diagnostic codes for both influenza and tracheostomy. Our primary predictor was receipt of anti-influenza medications on hospital day 0 or 1. We used propensity score matching to adjust for confounding by indication. Primary outcomes were length of stay (LOS) and 30-day all-cause revisit rate (emergency department visit or hospital admission). RESULTS Of 1436 discharges screened, 899 met inclusion criteria. The median admission age was 5 years (interquartile range: 2-10). The majority had multiple complex chronic conditions (median 3; interquartile range: 3-4) and technology dependence, such as gastrostomy tube (73.6%). After matching 772 unique admissions by propensity score, LOS was shorter for the cohort receiving early anti-influenza medications (6.4 vs 7.5 days; P = .01) without increase in revisit rate (27.5% vs 24.1%; P = .28). More than 80% in both cohorts received empirical antibiotics, and the duration of antibiotic therapy was similar (5.0 vs 5.6 days; P = .11). CONCLUSIONS Early use of anti-influenza medications in children with tracheostomy hospitalized with influenza is associated with shorter LOS, but these children continue to receive antibiotics despite identification and treatment of their viral infections.
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Affiliation(s)
- Ryo Miyakawa
- Divisions of Pediatric Pulmonology and Sleep Medicine
| | - Nicolas B Barreto
- Department of Psychology, Claremont Graduate University, Claremont, California; and
| | - Roberta M Kato
- Divisions of Pediatric Pulmonology and Sleep Medicine
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael N Neely
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
- Infectious Diseases, and
| | - Christopher J Russell
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
- Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
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27
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Russell CJ. Complication Versus Consequence: Defining Device-Related Outcomes in Children With Medical Complexity. Hosp Pediatr 2019; 9:70-71. [PMID: 30530804 DOI: 10.1542/hpeds.2018-0230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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28
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Russell CJ, Thurm C, Hall M, Simon TD, Neely MN, Berry JG. Risk factors for hospitalizations due to bacterial respiratory tract infections after tracheotomy. Pediatr Pulmonol 2018; 53:349-357. [PMID: 29314789 PMCID: PMC5815950 DOI: 10.1002/ppul.23938] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/28/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Identify characteristics associated with hospital readmission due to bacterial respiratory tract infections (bRTI) after tracheotomy. STUDY DESIGN Retrospective study of 8009 children 0-17 years undergoing tracheotomy from 2007 to 2013 at 48 children's hospitals in the Pediatric Health Information System database. The primary outcome was first hospital admission after tracheotomy for bRTI (ie, primary diagnosis of bRTI or a primary diagnosis of bRTI symptom and secondary diagnosis of bRTI). We used Cox-proportional hazard modeling to assess associations between patient demographic and clinical characteristics and bRTI hospital readmission. RESULTS Median age at tracheotomy admission was 5 months (interquartile range [IQR]: 1-50 months). Thirty-six percent (n = 2899) had at least one bRTI admission. Median time-to-readmission for bRTI was 275 days (IQR: 141-530). Factors independently associated with increased risk for bRTI readmission were younger age (eg, age < 30 days vs 13-17 years [aHR 1.32; 95%CI: 1.11-1.58]), Hispanic race/ethnicity (vs non-Hispanic White; aHR: 1.34; 95%CI: 1.20-1.50), government insurance (vs private; aHR 1.21; 95%CI: 1.10-1.33), >2 complex chronic conditions (vs zero; aHR 1.96; 95%CI: 1.34-2.86) and discharge to home (vs post-acute care setting; aHR 1.19; 95%CI: 1.08-1.32). Trauma diagnosis at tracheotomy (aHR 0.83; 95%CI: 0.69-1) and ventilator dependency (aHR 0.88; 95%CI: 0.81-0.97) were associated with decreased risk. CONCLUSIONS Young, Hispanic children with multiple complex chronic conditions who use Medicaid insurance and are not discharged to post-acute care are at the highest risk for hospital readmission for bRTI post-tracheotomy. Future research should investigate strategies to mitigate this risk for these children.
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Affiliation(s)
- Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Michael N Neely
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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29
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Russell CJ, Mamey MR, Koh JY, Schrager SM, Neely MN, Wu S. Length of Stay and Hospital Revisit After Bacterial Tracheostomy-Associated Respiratory Tract Infection Hospitalizations. Hosp Pediatr 2018; 8:hpeds.2017-0106. [PMID: 29339536 PMCID: PMC5790296 DOI: 10.1542/hpeds.2017-0106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify factors associated with longer length of stay (LOS) and higher 30-day hospital revisit rates for children hospitalized with bacterial tracheostomy-associated respiratory tract infections (bTARTIs). METHODS This was a multicenter, retrospective cohort study using administrative data from the Pediatric Health Information System database between 2007 and 2014 of patients 30 days to 17 years old with a principal discharge diagnosis of bTARTI or a principal discharge diagnosis of bTARTI symptoms with a secondary diagnosis of bTARTI. Primary outcomes of LOS (in days) and 30-day all-cause revisit rates (inpatient, observation, or emergency department visit) were analyzed by using a 3-level hierarchical regression model (discharges within patients within hospital). RESULTS We included 3715 unique patients and 7355 discharges. The median LOS was 4 days (interquartile range: 3-8 days), and the 30-day revisit rate was 30.5%. Compared with children 1 to 4 years old, children aged 30 days to 12 months had both longer LOS (adjusted length of stay [aLOS] = +0.9 days; 95% confidence interval [CI]: 0.6 to 1.3) and increased hospital revisit risk (adjusted odds ratio [aOR] = 1.5; 95% CI: 1.3 to 1.7). Other factors associated with longer LOS included public insurance (aLOS = +0.5 days; 95% CI: 0.2 to 0.8), 3 or more complex chronic conditions (CCCs), mechanical ventilation (acute or chronic), and empirical anti-Pseudomonas aeruginosa antibiotics (aLOS = +0.6 days; 95% CI: 0.3 to 0.9). Other factors associated with 30-day revisit included 4 or more CCCs (aOR = 1.3; 95% CI: 1.1 to 1.6) and chronic ventilator dependency (aOR = 1.1; 95% CI: 1.0 to 1.3). CONCLUSIONS Ventilator-dependent patients <12 months old with at least 4 CCCs are at highest risk for both longer LOS and 30-day revisit after discharge for bTARTIs. They may benefit from bTARTI prevention strategies and intensive care coordination while hospitalized.
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Affiliation(s)
- Christopher J Russell
- Divisions of Hospital Medicine and
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Joyce Y Koh
- Divisions of Hospital Medicine and
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Michael N Neely
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
- Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Susan Wu
- Divisions of Hospital Medicine and
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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30
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Yu H, Mamey MR, Russell CJ. Factors associated with 30-day all-cause hospital readmission after tracheotomy in pediatric patients. Int J Pediatr Otorhinolaryngol 2017; 103:137-141. [PMID: 29224755 PMCID: PMC5728177 DOI: 10.1016/j.ijporl.2017.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine factors associated with post-tracheotomy hospital readmission within 30 days of discharge. METHODS Children 18 years and younger who underwent tracheotomy at Children's Hospital Los Angeles (CHLA) between 1/1/2005 and 12/31/2013 with at least 30 days of follow-up at CHLA were identified through ICD-9 procedure codes. Patient characteristics and covariates were obtained by linking manual chart review and administrative data. We used multivariate logistic regression to identify the independent association between risk factors and the primary outcome of 30-day all-cause same-hospital readmission. RESULTS Of the 273 patients included, the median age at admission was 6 months [interquartile range (IQR): 1-51 months]. Among this primarily male (60.8%) and Hispanic (66.3%) cohort with a high proportion of discharge on positive pressure ventilation (47.1%), the 30-day readmission rate was 22% (n = 60). Of the readmissions, 92% (n = 55) were unplanned and 64% (n = 35) were associated with acute respiratory illnesses. Multivariate regression analysis demonstrated that, among patients ≤12 months, discharge on positive pressure ventilation [adjusted odds ratio (aOR) = 2.88, 95% confidence interval (CI) = 1.19-6.97] was associated with increased odds of readmission, while gastrostomy tube placement during the tracheotomy hospitalization (aOR = 0.42, 95% CI = 0.19-0.96) and prematurity (aOR = 0.35, 95% CI = 0.15-0.83) were associated with decreased odds of readmission. In patients >1 year of age, increased length of hospitalization (aOR = 1.01 per hospital day, 95% CI = 1-1.02) and presence of comorbid malignancy (aOR = 6.03, 95% CI = 1.25-29.16) were associated with increased odds of readmission. CONCLUSIONS Over one-fifth of children undergoing tracheotomy had an unplanned hospital readmission within 30 days after discharge. Because the majority of readmissions were unplanned and due to acute respiratory illnesses, future research should investigate how discharge procedures and improved care coordination may lower readmission rates in high-risk patients (e.g., patients discharged on positive pressure ventilation).
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Affiliation(s)
- Helena Yu
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mary Rose Mamey
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Russell CJ, Simon TD, Mamey MR, Newth CJL, Neely MN. Pseudomonas aeruginosa and post-tracheotomy bacterial respiratory tract infection readmissions. Pediatr Pulmonol 2017; 52:1212-1218. [PMID: 28440922 PMCID: PMC5561001 DOI: 10.1002/ppul.23716] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/31/2017] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Identify risk factors for readmission due to a bacterial tracheostomy-associated respiratory tract infection (bTARTI) within 12 months of discharge after tracheotomy. DESIGN/METHODS We performed a retrospective cohort study of 240 children who underwent tracheotomy and were discharged with tracheotsomy in place between January 1, 2005 and June 30, 2013. Children with prolonged total or post-tracheotomy length of stay (LOS), less than 12 months of follow-up, or who died during the index hospitalization were excluded. Readmission for a bTARTI (eg, pneumonia, tracheitis) treated with antibiotics, as ascertained by manual chart review, was the outcome variable. We used multivariate logistic regression to identify the independent association between risk factors and hospital readmission for bTARTI within 12 months. RESULTS At index hospitalizations for tracheotomy, the median admission age was 5 months (interquartile range [IQR] 2-43 months) and median LOS was 73 days (IQR 43-121 days). Most patients were of Hispanic ethnicity (n = 162, 68%) and were publicly insured (n = 213, 89%). Nearly half (n = 112, 47%) were discharged on positive pressure mechanical ventilation. Many (n = 103, 43%) were admitted for bTARTI within 12 months of discharge. Only Hispanic ethnicity (adjusted odds ratio [AOR] 2.0; 95% confidence interval [CI]: 1.1-3.9; P = 0.03) and acquisition of Pseudomonas aeruginosa between tracheotomy and discharge from index hospitalization (AOR 3.2; 95%CI: 1.2-8.3; P = 0.02) were independently associated with increased odds of bTARTI readmission, while discharge on gastrointestinal pro-motility agents was associated with decreased risk (AOR = 0.4; 95%CI: 0.2-0.8; P = 0.01). CONCLUSIONS Hispanic ethnicity and post-tracheotomy acquisition of P. aeruginosa during initial hospitalization are associated with bTARTI readmission.
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Affiliation(s)
- Christopher J Russell
- Divisions of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California
| | - Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Mary R Mamey
- Divisions of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher J L Newth
- Department of Pediatrics, Keck School of Medicine, University of Southern California.,Division of Critical Care, Children's Hospital Los Angeles, Los Angeles, California
| | - Michael N Neely
- Department of Pediatrics, Keck School of Medicine, University of Southern California.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, California
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Russell CJ, Mack WJ, Schrager SM, Wu S. Care Variations and Outcomes for Children Hospitalized With Bacterial Tracheostomy-Associated Respiratory Infections. Hosp Pediatr 2017; 7:16-23. [PMID: 27998905 DOI: 10.1542/hpeds.2016-0104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Identify hospital-level care variations and association with length of stay (LOS) and hospital revisit in children with tracheostomies hospitalized for bacterial respiratory tract infections (bRTIs). METHODS A multicenter, retrospective cohort study that used the Pediatric Health Information System database between 2007 and 2014 of patients with tracheostomies aged ≤18 years with a primary diagnosis of bRTI (eg, tracheitis) or a primary diagnosis of a bRTI symptom (eg, cough) and a secondary diagnosis of bRTI. Primary outcomes were LOS and 30-day all-cause revisit rates. Secondary outcomes included hospital-level diagnostic testing and anti-Pseudomonas antibiotic use. We used mixed-effects negative binomial (for LOS) and logistic (for revisit) regression to explore the relationship between hospital-level diagnostic test utilization and the outcomes. RESULTS Data representing 4137 unique patients with a median age of 3 years (interquartile range: 1-9 years) were included. Median LOS was 4 days (interquartile range: 3-8 days), and the 30-day revisit rate was 24.9%. Use of diagnostic testing and empirical anti-Pseudomonas antibiotics varied significantly among hospitals (all P values <.001). After adjusting for patient and hospital characteristics, compared with low test utilization hospitals, there were no differences in 30-day all-cause revisit rates in moderate (adjusted odds ratio: 1.19; 95% confidence interval [CI]: 0.93-1.52) or high (adjusted odds ratio: 1.07; 95% CI: 0.82-1.39) utilization hospitals. LOS in hospitals with moderate (% difference: -0.8%; 95% CI: -14.4-14.9%) or high (% difference: 13.9%; 95% CI: -0.7-30.6%) test utilization was not significantly longer. CONCLUSIONS Given that care variations were not associated with outcomes, future research should focus on standardizing diagnosis and treatment of bRTIs and readmission prevention in this population.
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Affiliation(s)
- Christopher J Russell
- Department of Pediatrics and .,Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Wendy J Mack
- Division of Biostatistics, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Susan Wu
- Department of Pediatrics and.,Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Flores G, Mendoza FS, Fuentes-Afflick E, Mendoza JA, Pachter L, Espinoza J, Fernandez CR, Arnold DDP, Brown NM, Gonzalez KM, Lopez C, Owen MC, Parks KM, Reynolds KL, Russell CJ. Hot topics, urgent priorities, and ensuring success for racial/ethnic minority young investigators in academic pediatrics. Int J Equity Health 2016; 15:201. [PMID: 27938389 PMCID: PMC5148862 DOI: 10.1186/s12939-016-0494-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 12/06/2016] [Indexed: 11/16/2022] Open
Abstract
Background The number of racial/ethnic minority children will exceed the number of white children in the USA by 2018. Although 38% of Americans are minorities, only 12% of pediatricians, 5% of medical-school faculty, and 3% of medical-school professors are minorities. Furthermore, only 5% of all R01 applications for National Institutes of Health grants are from African-American, Latino, and American Indian investigators. Prompted by the persistent lack of diversity in the pediatric and biomedical research workforces, the Academic Pediatric Association Research in Academic Pediatrics Initiative on Diversity (RAPID) was initiated in 2012. RAPID targets applicants who are members of an underrepresented minority group (URM), disabled, or from a socially, culturally, economically, or educationally disadvantaged background. The program, which consists of both a research project and career and leadership development activities, includes an annual career-development and leadership conference which is open to any resident, fellow, or junior faculty member from an URM, disabled, or disadvantaged background who is interested in a career in academic general pediatrics. Methods As part of the annual RAPID conference, a Hot Topic Session is held in which the young investigators spend several hours developing a list of hot topics on the most useful faculty and career-development issues. These hot topics are then posed in the form of six “burning questions” to the RAPID National Advisory Committee (comprised of accomplished, nationally recognized senior investigators who are seasoned mentors), the RAPID Director and Co-Director, and the keynote speaker. Results/conclusions The six compelling questions posed by the 10 young investigators—along with the responses of the senior conference leadership—provide a unique resource and “survival guide” for ensuring the academic success and optimal career development of young investigators in academic pediatrics from diverse backgrounds. A rich conversation ensued on the topics addressed, consisting of negotiating for protected research time, career trajectories as academic institutions move away from an emphasis on tenure-track positions, how “non-academic” products fit into career development, racism and discrimination in academic medicine and how to address them, coping with isolation as a minority faculty member, and how best to mentor the next generation of academic physicians.
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Affiliation(s)
- Glenn Flores
- Medica Research Institute, Mayo Clinic, and University of Minnesota School of Public Health, MR-CW105, P.O. Box 9310, Minneapolis, MN, 55440, USA.
| | - Fernando S Mendoza
- Stanford University School of Medicine, Medical School Office Bldg., X240, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Elena Fuentes-Afflick
- University of California, San Francisco, School of Medicine, 1001 Potrero Ave, SFGH 5, San Francisco, CA, 94110, USA
| | - Jason A Mendoza
- University of Washington School of Medicine, and Seattle Children's Research Institute, Suite 400, M/S: CW8-6, PO Box 5371, Seattle, WA, 98145, USA
| | - Lee Pachter
- Drexel University School of Medicine and St. Christopher's Hospital for Children, 160 East Erie Ave, Philadelphia, PA, 19134, USA
| | - Juan Espinoza
- Children's Hospital of Los Angeles and the Keck School of Medicine, University of Southern California, 4650 Sunset Blvd., MS 76, Los Angeles, CA, 90027, USA
| | - Cristina R Fernandez
- Columbia University Medical Center, 630 West 168th Street, Presbyterian Bldg 17-201I, New York, NY, 10032, USA
| | - Danielle D P Arnold
- University of Colorado School of Medicine, 13123 E. 16th Ave, B-158, Aurora, CO, 80045, USA
| | - Nicole M Brown
- The Children's Hospital of Montefiore, 3444 Kossuth Ave, 1st Floor, Bronx, NY, 10467, USA
| | - Kymberly M Gonzalez
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, 13th Floor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Cynthia Lopez
- University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC 7808, San Antonio, TX, 78229, USA
| | - Mikah C Owen
- University of Florida College of Medicine, 841 Prudential Dr, Suite 1330, Jacksonville, FL, 32207, USA
| | - Kenya M Parks
- University of Texas Medical School at Houston, 6431 Fannin St., JJL495, Houston, TX, 77030, USA
| | - Kimberly L Reynolds
- University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Christopher J Russell
- Children's Hospital of Los Angeles and the Keck School of Medicine, University of Southern California, 4650 Sunset Blvd., MS 76, Los Angeles, CA, 90027, USA
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Chen NY, Nguyen E, Schrager SM, Russell CJ. Factors Associated With the Prophylactic Prescription of a Bowel Regimen to Prevent Opioid-Induced Constipation. Hosp Pediatr 2016; 6:677-683. [PMID: 27803072 PMCID: PMC5794492 DOI: 10.1542/hpeds.2016-0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Identify factors associated with the prophylactic prescription of a bowel regimen with an inpatient opioid prescription. METHODS This was a retrospective cohort study from June 1, 2013, to October 31, 2014 of pediatric inpatients prescribed an oral or intravenous opioid on the general medical/surgical floors. We identified patients with or without a prophylactic prescription of a bowel regimen. We obtained patient demographics, prescriber training level and service and used multivariate logistic regression to analyze the factors associated with prophylactic bowel regimen and opioid prescription. RESULTS Of the 6682 encounters that met study criteria, only 966 (14.5%) encounters had prophylactic prescriptions. Patient factors associated with prophylactic prescription include increasing age (per year; odds ratio [OR] = 1.06, 95% confidence interval [CI] 1.05-1.07) and sickle cell diagnosis (OR = 3.19, 95% CI 2.08-4.91). Medication factors associated with prophylactic prescription include a scheduled opioid prescription (OR = 1.75, 95% CI 1.46-2.1) and a prescription for oxycodone (OR = 3.59, 95% CI 2.57-5.00) or morphine (OR = 1.84, 95% CI 1.39-2.44), compared with acetaminophen-hydrocodone. Compared with medical providers, surgeons were less likely (OR = 0.43, 95% CI 0.35-0.53) and pain service providers were more likely to prescribe a prophylactic bowel regimen (OR = 4.12, 95% CI 3.13-5.43). CONCLUSIONS More than 85% of inpatient opioid prescriptions did not receive a prophylactic bowel regimen. Future research should examine factors (eg, clinical decision support tools) to increase prophylactic prescription of bowel regimens with opioids for populations found to have lower rates.
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Affiliation(s)
- Nancy Y Chen
- Division of Hospital Medicine, Phoenix Children's Hospital, Phoenix, Arizona;
| | - Eugene Nguyen
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Trost MJ, Cowell M, Cannon J, Mitchell K, Waloff K, Avila H, Chand S, Russell CJ. Risk factors for overnight respiratory events following sedation for magnetic resonance imaging in children with sleep apnea. Sleep Breath 2016; 21:137-141. [PMID: 27683261 DOI: 10.1007/s11325-016-1410-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/22/2016] [Accepted: 09/15/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE Children with sleep apnea may be at increased risk for overnight respiratory events (ORE) following anesthesia. We sought to identify ORE risk factors in sleep apnea patients sedated for magnetic resonance imaging (MRI). METHODS One thousand four hundred seven hospitalizations for children with sleep apnea (by ICD-9 code) occurred at our institution from 5/1/2011 to 2/1/2015. One hundred twenty-seven (9 %) encounters were solely for post-MRI observation representing 96 unique patients. The first post-MRI admission for each patient underwent chart review. ORE was defined as sustained oxygen saturation <90 % with need for increased oxygen or adjustment of respiratory support after release from recovery. Characteristics of patients with and without ORE were compared by chi-squared analysis or independent samples t test. Logistic regression identified associations with ORE. RESULTS Ten out of 96 (10.4 %) patients had ORE. The average time following sedation to ORE was 10.25 h. ORE patients were hospitalized longer (median 2 vs. 1 day, p < 0.001). Overall, patients were 55 % male, 60 % Hispanic, with median age of 5 years [IQR 2-10] and median body mass index (BMI) of 17.9 [IQR 15.2-24]. On logistic regression, apnea-hypopnea index (AHI; OR 1.007 [95 % CI 1.002-1.011]), anesthesia complication (OR 1.13 [95 % CI 1.01-1.28]), and home non-invasive positive pressure ventilation (NIV; OR 6.08 [95 % CI 1.57-26.17]) were associated with ORE. CONCLUSION Ninety percent of children with sleep apnea admitted for overnight observation following sedated MRI did not have an ORE. AHI, anesthesia complications, and NIV use may help target higher-risk patients and avoid unnecessary hospitalizations.
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Affiliation(s)
- Margaret J Trost
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA. .,University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Melissa Cowell
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jennifer Cannon
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kendra Mitchell
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kevin Waloff
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Humberto Avila
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sanjay Chand
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd. #94, Los Angeles, CA, 90027, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Russell CJ, Shiroishi MS, Siantz E, Wu BW, Patino CM. The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review. BMC Pulm Med 2016; 16:40. [PMID: 26956371 PMCID: PMC4784295 DOI: 10.1186/s12890-016-0202-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 02/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background Ventilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines. Methods We conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook’s “Risk of Bias” assessment tool. Results Six studies met full inclusion criteria. For the systemic review’s primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis. Conclusions There is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled antibiotic therapy for VAP and VAT. Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0202-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #94, Los Angeles, California, 90027, USA. .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | - Mark S Shiroishi
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | - Elizabeth Siantz
- School of Social Work, University of Southern California, Los Angeles, California, USA.
| | - Brian W Wu
- MD-PhD Program, Keck School of Medicine, University of Southern California, Los Angeles, Calfornia, USA.
| | - Cecilia M Patino
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Abstract
Children with medical complexity are a subset of patients with special health care needs whose "health and quality of life depend on integrating health care between a primary care medical home, tertiary care services, and other important loci of care such as transitional care facilities, rehabilitation units, the home, the school, and other community based settings," according to Cohen et al. These children are characterized by (1) substantial health care service needs, (2) one or more severe chronic clinical condition(s), (3) severe functional limitations, and (4) high projected use of health resources that may include frequent or prolonged hospitalization, multiple surgeries, or the ongoing involvement of multiple subspecialty services and providers. Children with medical complexity are an important population for pediatric hospitalists, particularly those practicing in tertiary care settings. Recent studies describe the increasing prevalence of complex chronic conditions among all pediatric hospitalizations in the United States. This article reviews the definitions of children with medical complexity and recent studies describing the changes in hospital utilization for this group. We discuss issues in their inpatient care, including (1) intensive care coordination needs, (2) critical decision-making that occurs in the inpatient setting, (3) common clinical issues that occur with technology dependence (tracheostomies, feeding tubes, and cerebrospinal fluid shunts), and (4) common reasons for admission (eg, perioperative care, aspiration pneumonia, seizures, and feeding intolerance). Finally, we present a few important clinical questions regarding inpatient care for children with medical complexity that will require research in the coming years.
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O'Hare MF, Russell CJ, Leahey WJ, Varma MP, Murnaghan GA, McDevitt DG. Sotalol in the management of hypertension complicating pregnancy [proceedings]. Br J Clin Pharmacol 2012. [DOI: 10.1111/j.1365-2125.1979.tb04737.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Russell CJ, Golub SA, Cohen DE, Mayer KH. Urine-based asymptomatic urethral gonorrhea and chlamydia screening and sexual risk-taking behavior in men who have sex with men in greater Boston. AIDS Patient Care STDS 2007; 21:205-11. [PMID: 17428188 DOI: 10.1089/apc.2006.0051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To assess the prevalence of asymptomatic urethral gonorrhea and chlamydia men who have sex with men (MSM) living in greater Boston, 206 men attending routine medical appointments consented to urine-based chlamydia and gonorrhea screening using urine LCR amplification. Of those screened, 201 patients also completed a seven-question survey to assess sexual risk behaviors associated with urethral sexually transmitted infections. Less than 1% of the asymptomatic patients screened tested positive for urethral chlamydia; none tested positive for urethral gonorrhea. Forty-eight percent reported multiple sexual partners in the 30 days prior to screening, with HIV-infected patients reporting fewer partners and less unprotected insertive anal sex than HIV-uninfected patients. Almost 25% of patients screened used the Internet in the 30 days prior to screening to find a sexual partner. Internet use was associated with increased numbers of sexual partners in the 30 days prior to screening. Findings suggest that asymptomatic urethral chlamydia and gonorrhea may be uncommon in MSM living in the greater Boston area and that the recent rise in the prevalence of sexually transmitted infections may not be due to untreated asymptomatic infections. Increased awareness of STD symptoms among patients and medical providers is critical to timely diagnosis and treatment of STDs in MSM.
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Affiliation(s)
- Christopher J Russell
- Fenway Community Health, Boston, Massachusetts., Current affiliation: Harvard Medical School, Boston, Massachusetts 02115, USA
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Cohen DE, Russell CJ, Golub SA, Mayer KH. Prevalence of hepatitis C virus infection among men who have sex with men at a Boston community health center and its association with markers of high-risk behavior. AIDS Patient Care STDS 2006; 20:557-64. [PMID: 16893325 DOI: 10.1089/apc.2006.20.557] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The present study sought to investigate the prevalence of hepatitis C virus (HCV) among men who have sex with men (MSM) seen at a community health center, and to examine risk factors associated with infection. The study population included 218 MSM who were screened for HCV infection during routine clinic visits from May through December, 2001. Eighty-four percent of those screened (n = 183) agreed to complete a self-report questionnaire assessing drug use, sexual practices, and medical history. Participants ranged in age from 22 to 54 years. The majority of participants (82%) self-identified as Caucasian and 35% were HIV-positive. Prevalence of HCV infection was 11.5%. Men infected with HCV were more likely than HCV uninfected men to be coinfected with HIV and hepatitis B, and to have a history of rectal or urethral gonorrhea. HCV-infected men were more likely to have seen blood on shared cocaine straws and to have used crack cocaine in the past 6 months. Overall, 12% of HCV-infected men reported no parenteral risk factors for HCV infection. HCV seropositivity was significantly associated with an aggregate score representing high-risk behavior in the past six months. HCV prevention and screening should target MSM engaging in high-risk sex. Conversely, HIV and sexually transmitted infection risk reduction interventions should be targeted at MSM with HCV.
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Affiliation(s)
- Daniel E Cohen
- Fenway Community Health, Boston, 7 Haviland Street, Massachusetts 02115, USA.
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Yu XG, Addo MM, Perkins BA, Wej F, Rathod A, Geer SC, Parta M, Cohen D, Stone DR, Russell CJ, Tanzi G, Mei S, Wurcel AG, Frahm N, Lichterfeld M, Heath L, Mullins JI, Marincola F, Goulder PJR, Brander C, Allen T, Cao Y, Walker BD, Altfeld M. Differences in the expressed HLA class I alleles effect the differential clustering of HIV type 1-specific T cell responses in infected Chinese and caucasians. AIDS Res Hum Retroviruses 2004; 20:557-64. [PMID: 15186531 DOI: 10.1089/088922204323087813] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
China is a region of the world with a rapidly spreading HIV-1 epidemic. Studies providing insights into HIV-1 pathogenesis in infected Chinese are urgently needed to support the design and testing of an effective HIV-1 vaccine for this population. HIV-1-specific T cell responses were characterized in 32 HIV-1-infected individuals of Chinese origin and compared to 34 infected caucasians using 410 overlapping peptides spanning the entire HIV-1 clade B consensus sequence in an IFN-gamma ELISpot assay. All HIV-1 proteins were targeted with similar frequency in both populations and all study subjects recognized at least one overlapping peptide. HIV-1-specific T cell responses clustered in seven different regions of the HIV-1 genome in the Chinese cohort and in nine different regions in the caucasian cohort. The dominant HLA class I alleles expressed in the two populations differed significantly, and differences in epitope clustering pattern were shown to be influenced by differences in class I alleles that restrict immunodominant epitopes. These studies demonstrate that the clustering of HIV-1-specific T cell responses is influenced by the genetic HLA class I background in the study populations. The design and testing of candidate vaccines to fight the rapidly growing HIV-1 epidemic must therefore take the HLA genetics of the population into account as specific regions of the virus can be expected to be differentially targeted in ethnically diverse populations.
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Affiliation(s)
- Xu G Yu
- Partners AIDS Research Center and Infectious Disease Division, Massachusetts General Hospital and Division of AIDS, Harvard Medical School, Boston, Massachusetts 02129, USA
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Qian J, Timko MT, Allen AJ, Russell CJ, Winnik B, Buckley B, Steinfeld JI, Tester JW. Solvophobic Acceleration of Diels−Alder Reactions in Supercritical Carbon Dioxide. J Am Chem Soc 2004; 126:5465-74. [PMID: 15113218 DOI: 10.1021/ja030620a] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The rate of the Diels-Alder reaction between N-ethylmaleimide and 9-hydroxymethylanthracene in supercritical carbon dioxide (scCO(2)) was determined by following the disappearance of 9-hydroxymethylanthracene with in situ UV/vis absorption spectroscopy. The reaction conditions were 45-75 degrees C and 90-190 bar, which correspond to fluid densities (based on pure carbon dioxide) ranging between approximately 340 and 730 kg m(-3). The measured reaction rate at low scCO(2) fluid densities was nearly 25x faster than that reported in acetonitrile at the same temperature (45 degrees C). An inverse relationship between reaction rate and fluid density/pressure was observed at all temperatures in scCO(2). The apparent activation volumes were large and positive (350 cm(3) mol(-1)) and only a weak function of reduced temperature. A solvophobic mechanism analogous to those observed in conventional solvents is postulated to describe (a) the rate acceleration observed for this reaction in scCO(2) relative to that in acetonitrile, (b) the observed relationship between reaction rate and pressure/temperature/density, and (c) the large, positive activation volumes. Solubility measurements in scCO(2), rate measurements in conventional solvents, and an empirical correlation are used to support this theory. Our results advance the general understanding of reactivity in supercritical fluids and provide a rationale for selecting reactions which can be accelerated when conducted in scCO(2).
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Affiliation(s)
- Jin Qian
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
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Frahm N, Korber BT, Adams CM, Szinger JJ, Draenert R, Addo MM, Feeney ME, Yusim K, Sango K, Brown NV, SenGupta D, Piechocka-Trocha A, Simonis T, Marincola FM, Wurcel AG, Stone DR, Russell CJ, Adolf P, Cohen D, Roach T, StJohn A, Khatri A, Davis K, Mullins J, Goulder PJR, Walker BD, Brander C. Consistent cytotoxic-T-lymphocyte targeting of immunodominant regions in human immunodeficiency virus across multiple ethnicities. J Virol 2004; 78:2187-200. [PMID: 14963115 PMCID: PMC369231 DOI: 10.1128/jvi.78.5.2187-2200.2004] [Citation(s) in RCA: 236] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although there is increasing evidence that virus-specific cytotoxic-T-lymphocyte (CTL) responses play an important role in the control of human immunodeficiency virus (HIV) replication in vivo, only scarce CTL data are available for the ethnic populations currently most affected by the epidemic. In this study, we examined the CD8(+)-T-cell responses in African-American, Caucasian, Hispanic, and Caribbean populations in which clade B virus dominates and analyzed the potential factors influencing immune recognition. Total HIV-specific CD8(+)-T-cell responses were determined by enzyme-linked immunospot assays in 150 HIV-infected individuals by using a clade B consensus sequence peptide set spanning all HIV proteins. A total of 88% of the 410 tested peptides were recognized, and Nef- and Gag-specific responses dominated the total response for each ethnicity in terms of both breadth and magnitude. Three dominantly targeted regions within these proteins that were recognized by >90% of individuals in each ethnicity were identified. Overall, the total breadth and magnitude of CD8(+)-T-cell responses correlated with individuals' CD4 counts but not with viral loads. The frequency of recognition for each peptide was highly correlated with the relative conservation of the peptide sequence, the presence of predicted immunoproteasomal cleavage sites within the C-terminal half of the peptide, and a reduced frequency of amino acids that impair binding of optimal epitopes to the restricting class I molecules. The present study thus identifies factors that contribute to the immunogenicity of these highly targeted and relatively conserved sequences in HIV that may represent promising vaccine candidates for ethnically heterogeneous populations.
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Affiliation(s)
- Nicole Frahm
- Partners AIDS Research Center, Endocrine Unit, Massachusetts General Hospital, Charlestown, Massachusetts 02129-2000, USA
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Abstract
OBJECTIVE The current study examined whether homosexuality is a specific risk factor for disordered eating in men. METHOD Men (64 heterosexual and 58 homosexual) completed the Beck Depression Inventory (BDI), the Rosenberg Self-Esteem Scale (RSE), the Masculinity and Femininity scales of the Bem Sex-Role Inventory (BSRI), the Bulimia Test-Revised (BULIT-R), the Eating Attitudes Test (EAT-26), and the Body Shape Questionnaire (BSQ). RESULTS Homosexual men had more pathological scores on the BDI, RSE, BULIT-R, EAT-26, and BSQ. Additionally, homosexual men reported greater discomfort with sexual orientation. After controlling for differences in depression, self-esteem, and comfort with sexual orientation, sexual orientation continued to account for significant variance in BULIT-R, EAT-26, and BSQ scores. DISCUSSION Future research may benefit from exploring aspects of homosexuality that may contribute specifically to risk for disordered eating in men.
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Abstract
Competency ratings were obtained from a hybrid selection system on 98 top-level executives in a predictive validity design. Hierarchical linear modeling results indicated that "resource problem-solving-oriented" competency ratings predicted initial performance. "People-oriented" competency ratings predicted subsequent performance trends. Utility estimates suggested that the system generated an additional $3 million in annual profit per candidate selected. Groups of executives with similar performance trends were identified who had encountered qualitatively different situational circumstances. Findings imply that a model of executive performance must contain main effects for person (competencies) and situation (economic-industrial) characteristics on both subsequent performance and performance trends. Future research needs to examine which situational circumstances moderate relationships between executive competencies and initial performance or subsequent performance trends.
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Affiliation(s)
- C J Russell
- Price College of Business, University of Oklahoma, Norman 73019-0450, USA.
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Abstract
The fusion (F) protein of the paramyxovirus SV5 strain W3A causes syncytium formation without coexpression of the SV5 hemagglutinin-neuraminidase (HN) glycoprotein, whereas the F protein of the SV5 strain WR requires coexpression of HN for fusion activity. SV5 strains W3A and WR differ by three amino acid residues at positions 22, 443, and 516. The W3A F protein residues P22, S443, and V516 were changed to amino acids found in the WR F protein (L22, P443, and A516, respectively). Three single-mutants, three double-mutants, and the triple-mutant were constructed, expressed, and assayed for fusion using three different assays. Mutant P22L did not cause fusion under physiological conditions, but fusion was activated at elevated temperatures. Compared with the W3A F protein, mutant S443P enhanced the fusion kinetics with a faster rate and greater extent, and had a lower activation temperature. Mutant V516A had little effect on F protein-mediated fusion. The double-mutant P22L,S443P was capable of causing fusion, suggesting that the two mutations have opposing effects on fusion activation. The WR F protein requires coexpression of HN to cause fusion at 37 degrees C, and does not cause fusion at 37 degrees C when coexpressed with influenza virus hemagglutinin (HA); however, at elevated temperatures coexpression of WR F protein with HA resulted in fusion activation. In the crystal structure of the core trimer of the SV5 F protein (Baker, K. A., Dutch, R. E., Lamb, R.A., and Jardetzky, T. S. (1999). Mol. Cell 3, 309-319), S443 is the last residue (with interpretable electron density) in an extended chain region and the temperature factor for S443 is high, suggesting conformational flexibility at this point. Thus, the presence of prolines at residues 22 and 443 may destabilize the F protein and thereby decrease the energy required to trigger the presumptive conformational change to the fusion-active state.
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Affiliation(s)
- R G Paterson
- Department of Biochemistry, Molecular Biology, and Cell Biology, Evanston, IL 60208-3500, USA
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Abstract
To better understand the roles of different regions of influenza hemagglutinin in membrane fusion, we have studied the fusion properties of large unilamellar vesicles in the presence of constructs comprising the 127 amino acid ectodomain of the HA2 fragment (FHA2) as well as mutated forms of FHA2 containing single amino acid substitutions, the 95 amino acid truncated form of FHA2 lacking the N-terminal fusion peptide (SHA2), the 20 amino acid N-terminal fusion peptide and the ten amino acid peptide corresponding to the kinked loop region of FHA2. The 100 nm liposomes were made from dioleoylphosphatidylethanolamine, dioleoylphosphatidylcholine and cholesterol in equimolar ratio. At pH 5 a high rate of lipid mixing was observed with FHA2 present, even at very low molar concentrations, whereas much lower rates were observed using the shorter constructs: SHA2, the fusion peptide, and the loop peptide. Concentrations of FHA2 which promoted extensive lipid mixing also induced leakage of aqueous contents. Marked effects of FHA2 were also observed with liposomes of egg phosphatidylcholine. All of the changes observed with the liposomes were highly pH-dependent, with only negligible changes occurring at pH 7. The results demonstrate the potent action of FHA2 in promoting lipid mixing and demonstrate the contribution of other regions of the ectodomain of FHA2, in addition to the fusion peptide, to the mechanism of acceleration of membrane fusion. The results also indicate that the pH dependence of fusion is not due solely to changes in the interactions between the HA1 and HA2 subunits. Thus, the "spring loaded energy" is not required to bring about the apposition of the two membranes, considering that FHA2 is already in its thermostable conformation. The acidic amino acid residues in the kinked loop region appear to play a particularly important role in the pH-dependent fusion process as demonstrated by the marked loss of lipid mixing activity of mutant forms of FHA2.
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Affiliation(s)
- R F Epand
- McMaster University Health Sciences Centre, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
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Russell CJ, Thorgeirsson TE, Shin YK. The membrane affinities of the aliphatic amino acid side chains in an alpha-helical context are independent of membrane immersion depth. Biochemistry 1999; 38:337-46. [PMID: 9890915 DOI: 10.1021/bi981179h] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Understanding, predicting, and designing the binding of peptides and proteins to bilayers require quantifying the intrinsic propensities of individual amino acid residues to bind membranes as a function of structural context and bilayer depth. A host-guest study was performed using the peptide host named helix5 in order to determine the membrane affinities of the aliphatic side chains both in an alpha-helical context and as a function of bilayer depth. Use of the alpha-helical host with a constrained geometry allowed the placement of guest sites at three different depths in bilayers and minimized secondary structural changes due to guest substitutions. Circular dichroism and electron paramagnetic resonance (EPR) were used to characterize the aqueous and bilayer-bound structures of the peptide variants. EPR was also used to measure the bilayer-water partition constants of the peptide variants, and the Delta DeltaGtr values (relative to Gly) of the aliphatic amino acid side chains were subsequently calculated. Surprisingly, the DeltaDeltaGtr values did not significantly vary as a function of the guest site depth in bilayers. In addition, the Delta DeltaGtr values determined in an alpha-helical context are reduced to approximately two-thirds of Delta DeltaGtr values determined in other studies for the bilayer-water and octanol-water partitioning of amino acid side chains in extended and unstructured hosts. Both the relative reduction in Delta DeltaGtr values in the context of an alpha-helical host and the invariance of Delta DeltaGtr values with respect to bilayer depth are consistent with the membrane affinities of the aliphatic residues being largely determined by the classical hydrophobic effect.
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Affiliation(s)
- C J Russell
- Department of Chemistry, University of California, Berkeley 94720, USA
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Russell CJ, King DS, Thorgeirsson TE, Shin YK. De novo design of a peptide which partitions between water and phospholipid bilayers as a monomeric alpha-helix. Protein Eng 1998; 11:539-47. [PMID: 9740371 DOI: 10.1093/protein/11.7.539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To dissect the determinants of protein insertion into membranes, we designed a model peptide which partitions between water and phospholipid bilayers as an alpha-helical monomer. We used a simplex method to optimize the 'a, d hydrophobicity' and 'e, g charge' of a series of five peptides, where 'abcdefg' correspond to the positions in two turns of an alpha-helix. Circular dichroism and analytical ultra-centrifugation experiments showed that the final peptide (helix5) is monomeric and has an alpha-helix content of approximately 89% at 0 degrees C in aqueous solution. In the presence of large unilamellar vesicles (LUVs), helix5 partitions between the aqueous and membranous phases with a partition constant well suited for measurements by electron paramagnetic resonance (EPR) spectroscopy. EPR power saturation experiments with a cysteine-scanning strategy showed that the alpha-helicity of helix5 is conserved upon binding to LUVs and that the alpha-helix binds parallel to the membrane surface with the central axis approximately 5 A below the lipid phosphate groups. Helix5 should be a useful model peptide for studies aimed at dissecting the determinants of the membrane binding of alpha-helices. The simplex-based strategy may be useful in the rational design of proteins when desired structural or partitioning properties cannot be selected or screened from libraries.
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Affiliation(s)
- C J Russell
- Department of Chemistry, University of California, Berkeley 94720, USA
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Watson I, Hill CM, Biggart JD, Russell CJ, Garrett PJ. Sarcoidosis and primary systemic vasculitis. Nephrol Dial Transplant 1996; 11:1631-3. [PMID: 8856225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- I Watson
- Renal Subregional Unit, Tyrone County Hospital, Omagh, Co Tyrone, N Ireland
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