Inpatient Practice Research Articles

Inpatient Use of Extended-Release (ER) Opioids for Vaso-Occlusive Crisis Associated with Increased Length of Stay for ER Opioid-Naïve Patients

Background: The intermittent acute pain syndrome associated with sickle cell disease (SCD) is a poorly understood phenomenon with complex pathophysiology. Given the broad spectrum of analgesic interventions, including immediate-release (IR) and extended-release (ER) opioids, healthcare providers are challenged with the task of safely and effectively escalating inpatient opioid regimens, especially in the setting of limited guidelines outlining the combination of different opioid formulations. Despite SCD being the most common genetic disorder in the United States, more research is required to improve physician expertise with appropriate and timely pain management of vaso-occlusive crisis. Methods: This study was a retrospective chart review (n=200) of patients with known SCD requiring hospitalization for acute pain secondary to vaso-occlusive crisis without an alternative etiology of pain symptoms. The review included a patient population aged 18-67 years old with 43.5% males and 56.5% females hospitalized from 2/1/2022 to 5/6/2022. The primary outcome measure was hospital length of stay (LOS) for adequate pain control compared against varying factors of inpatient opioid-prescribing practices, including initiation or continuation (if prescribed within 6 months prior to admission encounter per PDMP review) of an ER opioid formulation, degree of morphine milligram equivalents (MME) escalation from outpatient regimen, utilization of a sickle cell analgesic order set, and initiation of patient-controlled analgesia pump (PCA). A secondary outcome measure investigated was the quantitative comparison of highest daily prescribed MME in relation to the aforementioned inpatient variables. Data analysis was completed using Wilcoxon Rank Summary analysis, with a significant p-value set to < 0.05. Results: Among the primary outcome analysis, the only significant factor affecting LOS was the introduction of an ER opioid. The results show that within the patient cohort naïve to an outpatient ER opioid (n=105), ER opioid-incorporated inpatient analgesic regimens resulted in a significantly increased mean LOS compared to IR opioid monotherapy regimens, with an average of 8.8 inpatient days as compared to 5.3 days, respectively (p-value < 0.001). For the patients prescribed an outpatient ER opioid at baseline (n=95), the continuation of an inpatient ER opioid did not result in a significant change in mean LOS, calculated as 6.7 days vs. 6.0 days in the continued and non-continued groups, respectively (p-value = 0.716). Among the secondary outcome measures, utilization of a sickle cell order set and PCA did not significantly affect degree of MME escalation. Conclusions: Limited evidence-based recommendations for the treatment of acute pain episodes in SCD has resulted in widely varying opioid regimens prescribed by inpatient providers and has created clinical challenges regarding the optimization of pain management. This study investigated inpatient opioid regimens utilized in treatment of vaso-occlusive crisis and found that the initiation of ER opioids resulted in increased length of stay for ER opioid-naïve patients as compared to treatment with IR opioids alone. These results question the benefit of inpatient ER opioids in relation to the risk of opioid dependence and MME escalation.

Therapeutic Drug Level Monitoring of Antipsychotics at an Inpatient Psychiatric Hospital.

The American Psychiatric Association guidelines for the treatment of patients with schizophrenia state that the utility of antipsychotic therapeutic drug monitoring (TDM) remains unclear, except for clozapine or assessing adherence. The aim of this study was to investigate the extent and impact of antipsychotic TDM in inpatient practice to improve its utilization. Patients with antipsychotic blood levels drawn between May 1, 2021 and January 31, 2023 were invited to consent for retrospective chart data analysis to determine the influence of antipsychotic blood levels on their treatment. Approximately 42% of patients consented. Data collected from the patients' electronic medical records included age, ethnicity, race, sex, diagnosis, comorbidities, adverse drug reactions, medications, doses and frequency, antipsychotics and levels, laboratory values, and treatment history. Comparisons were made between antipsychotic levels that were within and outside the therapeutic range and the status of antipsychotic regimen adjustments. A total of 135 antipsychotic levels from 40 inpatients were analyzed. Approximately 48% of the levels were appropriately drawn, whereas 52% were inappropriately drawn. Clozapine had the highest TDM rate (59%) and the most common diagnoses were schizophrenia (45%) and schizoaffective disorder (32.5%). More levels were appropriately drawn for clozapine (47.3% versus 24.3%) than for risperidone (41% versus 46.2%). Appropriately drawn clozapine levels correlated with higher daily doses and levels at or above the therapeutic threshold of 350 ng/mL. Most antipsychotic drug levels were inappropriately drawn, emphasizing the complexity and potential for errors in TDM. Although more patients were prescribed risperidone, clozapine had the highest TDM rate. Clinicians were more likely to keep antipsychotic regimens unchanged for appropriately drawn levels and adjust doses for inappropriately drawn levels.

Biliary sludge syndrome induced by cephalosporins in children: clinical and diagnostic markers, management

Biliary sludge can occur when taking medicines (oral contraceptives, cephalosporins, octreotide, furosemide, clofibrate, morphine, calcium preparations, etc.). In particular, 30–40 % of ceftriaxone, which is widely used in pediatric inpatient practice, is excreted with bile, 5–15 % of all side effects of the drug are due to biliary sludge. The mechanism of ceftriaxone-associated biliary sludge is due to the fact that ceftriaxone competes with bilirubin for albumin, which induces an increase in unconjugated bilirubin in the blood. The drug enters the bile in the form of a divalent anion, binds to calcium in ceftriaxone-calcium complexes with inclusions of cholesterol monohydrate crystals and bilirubinate granules. In patients taking cephalosporins, when complaints from the gastrointestinal tract appear, ultrasound screening is mandatory. Children with a family history of gallstone disease and risk factors should undergo ultrasound screening on the 10th day and 1 month after treatment with cephalosporins, even in the absence of complaints. The administration of ursodeoxycholic acid leads to a significant regression of clinical symptoms of biliary sludge and objective ultrasound signs in 2/3 of children after 2 months.

Stroke Inpatient Rehabilitation Environments: Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping.

Stroke inpatient rehabilitation is a complex process involving stroke survivors, staff, and family utilizing a common space for a shared purpose: to optimize recovery. This complex pathway is rarely fully described. Stroke care is ideally guided by Clinical Practice Guidelines, and the rehabilitation built environment should serve to optimize care delivery, patient and staff experience. We aimed to articulate the inpatient stroke rehabilitation process of care in a series of process maps, and to understand the degree to which current stroke clinical and building construction (ie, design) guidelines align to support inpatient stroke rehabilitation. We used the Value-Focused Process Engineering methodology to create maps describing the events and activities that typically occur in the current stroke inpatient rehabilitation service model. These maps were completed through individual and group session consultations with stroke survivors, architects, policy makers, and clinical experts. We then determined which sections of the Australian Stroke Rehabilitation Guidelines and the Australasian Health Facility Design Guidelines could be aligned and applied to the process maps. We present a summary process map for stroke inpatient rehabilitation, alongside detailed process maps for 4 different phases of rehabilitation (admission, a normal weekday, a weekend day, and discharge) using Value-Focused Process Engineering notation. The integration of design and clinical guidelines with care pathway maps revealed where guidelines lack detail to be readily linked to current stroke inpatient care practice, providing an opportunity to design stroke inpatient rehabilitation spaces based on the activities occurring within them. Our findings highlight gaps where clinical and design experts should work together to use guidelines to their full potential; and to improve the process of planning for future stroke rehabilitation units.

Association of hospital spending with care patterns and mortality in patients hospitalized with community-acquired pneumonia.

Pneumonia is a leading cause of mortality and intensive therapy is costly. However, it is unclear whether more spending is associated with better patient outcomes or how hospitals could decrease costs. This study investigates the association between hospital spending and 14-day inpatient mortality among community-acquired pneumonia inpatients. This retrospective cohort study focused on adult pneumonia patients discharged between July 2010 and June 2015 from 260 UShospitals in the Premier database. Hospitals were divided into four pneumonia cost-of-care quartiles and average cost was calculated for each hospital. Odds of 14-day inpatient mortality and care practices were compared among high and low-cost hospitals. The study population comprised 534,038 patients with a mean age 69.5 (SD 16.3); 51.9% were female, 75% White, and 71.9% covered by Medicare. Hospitals were largely medium-sized (40.4%), located in the South (49.2%), and in urban areas (82.3%). The fully adjusted population-averaged cost was 14,486 US dollars (95% confidence interval [CI] 13,982-14,867). Hospital practices associated with cost included intensity of diagnostic work-up +$14 (95% CI+12 to +18; p < .0001) and de-escalation of antibiotic therapy, +$6836 (95% CI+2291 to +11,160; p = .004). There was no significant difference in odds of 14-day inpatient mortality between hospitals in the highest and lowest cost quartiles. Greater spending at the hospital level was not associated with lower mortality. Lower diagnostic costs were associated with lower cost of care, suggesting that judicious use of diagnostic testing might reduce costs without worsening patient outcomes.

Characterizing the Patterns of Electronic Health Record-Integrated Secure Messaging Use: Cross-Sectional Study.

Communication among health care professionals is essential for the delivery of safe clinical care. Secure messaging has rapidly emerged as a new mode of asynchronous communication. Despite its popularity, relatively little is known about how secure messaging is used and how such use contributes to communication burden. This study aims to characterize the use of an electronic health record-integrated secure messaging platform across 14 hospitals and 263 outpatient clinics within a large health care system. We collected metadata on the use of the Epic Systems Secure Chat platform for 6 months (July 2022 to January 2023). Information was retrieved on message volume, response times, message characteristics, messages sent and received by users, user roles, and work settings (inpatient vs outpatient). A total of 32,881 users sent 9,639,149 messages during the study. Median daily message volume was 53,951 during the first 2 weeks of the study and 69,526 during the last 2 weeks, resulting in an overall increase of 29% (P=.03). Nurses were the most frequent users of secure messaging (3,884,270/9,639,149, 40% messages), followed by physicians (2,387,634/9,639,149, 25% messages), and medical assistants (1,135,577/9,639,149, 12% messages). Daily message frequency varied across users; inpatient advanced practice providers and social workers interacted with the highest number of messages per day (median 19). Conversations were predominantly between 2 users (1,258,036/1,547,879, 81% conversations), with a median of 2 conversational turns and a median response time of 2.4 minutes. The largest proportion of inpatient messages was from nurses to physicians (972,243/4,749,186, 20% messages) and physicians to nurses (606,576/4,749,186, 13% messages), while the largest proportion of outpatient messages was from physicians to nurses (344,048/2,192,488, 16% messages) and medical assistants to other medical assistants (236,694/2,192,488, 11% messages). Secure messaging was widely used by a diverse range of health care professionals, with ongoing growth throughout the study and many users interacting with more than 20 messages per day. The short message response times and high messaging volume observed highlight the interruptive nature of secure messaging, raising questions about its potentially harmful effects on clinician workflow, cognition, and errors.

Practical Considerations in Hospital Infection Prevention

Inpatient infection prevention practices vary widely between health care institutions, on a national and international scale. Transmissible infectious diseases pose a risk to vulnerable inpatient populations as well as hospital staff and visitors. Maintaining a high index of suspicion, along with early identification and prompt isolation procedures of patients with these conditions can greatly reduce the likelihood of transmission. We review the presenting features and recommended infection prevention practices for six transmissible infectious diseases known to pose risks to patients, staff and visitors: scabies, tuberculosis, respiratory viruses, varicella zoster virus, Clostridioides difficile, and syphilis.

The Role of Local Therapy in The Treatment of Patients with Acute Rhinosinusitis in Outpatient Settings

Acute rhinosinusitis is one of the most common diseases encountered in the practice of an otorhinolaryngologist. The frequency of visits from patients with acute rhinosinusitis is increasing both in outpatient and inpatient practice. Despite the development of modern medicine, the relevance of the problem of this disease is growing every year, and this has a number of reasons. In the first hours and days of the disease, local treatment is very important, which helps to quickly stop inflammation and achieve recovery without the use of systemic antibacterial drugs

Lost in Transition: Missed Opportunities for the 4Ms to Support Post-Acute Care Transitions.

Thousands of health systems have adopted the 4Ms framework, a set of evidence-based practices specific to older adults, as part of the Age-Friendly Health Systems (AFHS) initiative. However, implementation efforts have largely been setting-specific and approaches to achieve continuity of the 4Ms during care transitions are nascent. Transitions from hospitals to skilled nursing facilities (SNFs) are one type of care transition that would greatly benefit from continuity of 4Ms practices. Drawing from the authors' insights and 5 exploratory interviews at 3 health systems that implemented the 4Ms in the inpatient setting, we describe a set of current-state challenges when trying to extend specific inpatient 4Ms practices (eg, deprescribing of high-risk medications) as well as the nuanced understanding of the individual's clinical trajectory developed during an inpatient stay. We also offer concrete opportunities, such as developing 4 Ms-centric discharge summary templates, to address the challenges. With the large investment in AFHS transformation and associated efforts to implement the 4Ms framework in all care settings used by older adults, it is critical to raise awareness of the specific obstacles to promoting continuity of successful 4Ms practices during care transitions and work to overcome them. Our insights from hospital-to-SNF transitions offer a starting point.

YANIK YARALANMASI OLAN HASTANEYE YATIRILAN ERİŞKİN HASTALARDA AĞRI KESİCİ KULLANMA ALIŞKANLIKLARI

Objectives: Modern burn care is dependent on the effective management of burn pain. Although opioids remain the cornerstone of treatment, their adverse effects remain serious. In this study, we investigated non-opioid painkillers, including acetaminophen and dexketoprofen, which are commonly used in the clinical practice for adult burn inpatients who do not require admission to an intensive care unit.&#x0D; Methods: Thirteen consecutive inpatients with burns were included in this study. During the six-day period, the patients self-administered painkillers as needed. The time of medication intake was recorded, and a visual analog scale was used to assess pain. Thereafter, statistical analyses were performed.&#x0D; Results: No significant differences were observed between age and sex groups. As the percentage of burns increased, the number of painkillers used also increased. It was found that the patients took painkillers most frequently at 11 o'clock (when the wound dressing was changed) and least frequently at 14 o'clock. No significant difference was observed between the effects of dexketoprofen and paracetamol in reducing pain.&#x0D; Conclusions: The need for painkillers in patients with burns varies throughout the day. The effectiveness of acetominophen and dexketoprofen during the day was higher than that during dressing changes. The total body surface area should be considered with regards to the amount and frequency of painkiller administered.

Preparedness and training of genetic counselors practicing in inpatient settings.

As rapid genomic testing technology increasingly allows for real-time answers that could alter management for acutely ill patients, opportunities for genetic counselors to work in inpatient settings will increase. However, genetic counselors' preparedness and the training provided by graduate programs to work in inpatient settings are unknown. We conducted semi-structured interviews with 13 genetic counselors who provided services in varied inpatient settings to assess genetic counselors' readiness for inpatient positions. We also surveyed members of the Association of Genetic Counseling Program Directors (AGCPD) about inpatient training practices of genetic counseling graduate programs. Genetic counselors were recruited through the National Society of Genetic Counselors (NSGC) Inpatient Special Interest Group listserv and graduate program faculty were recruited through the AGCPD listserv. Some challenges reported by genetic counselors in inpatient settings included working in a fast-paced hospital environment which necessitated focused interactions with patients; collaborating with diverse providers who may not understand the role of genetic counselors; and navigating grief experiences of families and of themselves as a provider. Although genetic counselors felt that many of their skills developed in graduate school were transferrable to the inpatient setting, those who had minimal or no inpatient exposure in graduate school often described feeling unprepared for working in the inpatient setting. The majority of AGCPD respondents (23/28) indicated their program provided some type of exposure to the inpatient setting for students, the most common (22/23) being an inpatient clinical rotation, which suggests many graduate programs are already recognizing the importance of providing inpatient training. Our findings indicate that while many skills are transferrable to inpatient positions, genetic counselors face unique challenges in inpatient settings. Our results suggest that graduate exposure to the inpatient setting and professional support of inpatient genetic counselors are beneficial to support genetic counselors' preparedness to take on inpatient positions.

Impact of the COVID-19 Pandemic on Medical Education during Inpatient Internal Medicine Rounds.

Inpatient rounding is a foundational component of medical education in academic hospitals. The coronavirus 2019 (COVID-19) pandemic disrupted traditional inpatient rounding practices. The objectives of this study were to describe how Internal Medicine inpatient team rounding changed because of COVID-19-related precautions and the effect of these changes on education during rounds. During February to March 2021, we conducted four virtual focus groups with medical and physician assistant students, interns, upper-level residents, and attending physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, and designed a codebook to categorize focus group commentary. Focus groups revealed that students believed that certain physical-distancing measures in place early on during the pandemic were ineffective and significantly limited their ability to evaluate patients in person. Residents described increased stress levels related to potential severe acute respiratory-coronavirus 2 exposure and limited time at the bedside, which affected their confidence with clinical assessments. Rounding-team fragmentation precluded the entire team learning from all of the patients on the team's census. Loss of intrateam camaraderie impaired the development of comfortable learning environments. This study evaluated Internal Medicine team member focus groups to describe how the COVID-19 pandemic affected medical education during rounds. Academic teaching programs can adapt the findings from this study to address and prevent pandemic-related gaps in medical education during rounds now and during future potential disruptions to medical education.

Current Inpatient Screening Practices for Sexual History and STIs: An Opportunity to Seize.

The American Academy of Pediatrics recommends utilizing hospitalizations as an opportunity to provide sexual health screenings for adolescents. This study aimed to describe the current practice of sexual history documentation (SHxD) and sexually transmitted infection (STI) testing among adolescents admitted to a pediatric hospital medicine service. Retrospective cross-sectional study of adolescents (14-19 years old) admitted to the PHM service from 2017-2019 was performed at an academic children's health system. Patient (demographics, history of complex chronic condition, and insurance), hospitalization (length of stay, diagnosis, STI tests ordered/results), and physician (level of training and gender) characteristics were extracted for each encounter. A natural language processing algorithm identified the presence of SHxD. Univariate analysis and multivariable analysis were performed to detect factors associated with SHxD and STI screening. The prevalence of STIs was calculated for those who were tested. Out of 2242 encounters, SHxD and STI testing rates were 40.9% and 17.2%, respectively. Patient gender, race, lack of complex chronic condition, and resident involvement were predictive of SHxD and STI testing. SHxD increased the odds of STI testing significantly (OR 5.06, CI 3.90-6.58). Among those who were tested, the prevalence of STIs was highest for chlamydia (37/329, 11.2%). Overall, sexual health screening rates remain low in the hospital setting and future improvement initiatives are needed.

Delay in treatment of adult hemophagocytic lymphohistiocytosis is associated with worse in-hospital outcomes.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by uncontrolled activation of the immune system leading to multiorgan failure. Timely initiation of HLH-specific treatment is believed to be essential and lifesaving. Due to the rarity of the condition in adults, there is no data available in the literature to investigate the effects of treatment delay in this age group. We used data from the National Inpatient Sample (NIS) to evaluate the inpatient practices of HLH treatment initiation over 13 years (2007-2019) and their association with clinically relevant inpatient outcomes. Patients were divided into early treatment group (<6 days) and late treatment group (≥ 6 days). We compared outcomes using multivariate logistic regression models adjusting for age, sex, race, and HLH-triggering conditions. There were 1327 and 1382 hospitalizations in the early and late treatment groups, respectively. Hospitalization in the late treatment group had higher rates of in-hospital mortality (OR 2.00 [1.65-2.43]), circulatory shock (OR 1.33 [1.09-1.63]), requiring mechanical ventilation (OR 1.41 [1.18-1.69]), venous thromboembolism (OR 1.70 [1.27-2.26]), infectious complications (OR 2.24 [1.90-2.64]), acute kidney injury (OR 2.27 [1.92-2.68]), and requiring new hemodialysis (OR 1.45 [1.17-1.81]). Additionally, we observed no significant trend in the mean time to treatment over the study period. This study shows the importance of early initiation of HLH treatment and highlights the adverse outcomes of treatment delay.

Improving Neurology Inpatient Fall Rate: Effect of a Collaborative Interdisciplinary Quality Improvement Initiative

ObjectiveTo reduce unwitnessed inpatient falls on the neurology services floor at an academic medical center by 20% over 15 months. Patients and MethodsA 9-item preintervention survey was administered to neurology nurses, resident physicians, and support staff. Based on survey data, interventions targeting fall prevention were implemented. Providers were educated during monthly in-person training sessions regarding the use of patient bed/chair alarms. Safety checklists were posted inside each patient’s room reminding staff to ensure that bed/chair alarms were on, call lights and personal items were within reach, and patients’ restroom needs were addressed. Preimplementation (January 1, 2020, to March 31, 2021) and postimplementation (April 1, 2021, to June 31, 2022) rates of falls in the neurology inpatient unit were recorded. Adult patients hospitalized in 4 other medical inpatient units not receiving the intervention served as a control group. ResultsRates of falls, unwitnessed falls, and falls with injury all decreased after intervention in the neurology unit, with rates of unwitnessed falls decreasing by 44% (2.74 unwitnessed falls per 1000 patient-days before intervention to 1.53 unwitnessed falls per 1000 patient-days after intervention; P=.04). Preintervention survey data revealed a need for education and reminders on inpatient fall prevention best practices given a lack of knowledge on how to operate fall prevention devices, driving the implemented intervention. All staff reported significant improvement in operating patient bed/chair alarms after intervention (P<.001). ConclusionA collaborative, multidisciplinary approach focusing on provider fall prevention education and staff checklists is a potential technique to reduce neurology inpatient fall rates.

Outpatient practice utilization for CAR-T and T cell engager in patients with lymphoma and multiple myeloma.

1533 Background: FDA-approved chimeric antigen receptor T-cell (CAR-T) and bispecific T cell engager (TCE) therapy are most commonly managed inpatient. Here we report our experience with hospital-based outpatient (HBO) management of patients (pts) receiving FDA-approved CAR-T or TCE and a predictive model for increased risk of early hospitalization (≤3 days post CAR-T). Methods: We reviewed the outcomes of pts who received FDA-approved CAR-T (axi-cel, brexu-cel, ide-cel, cilta-cel) or TCE (teclistamab) in the HBO unit between 3/2021 and 1/2023 at Mayo Clinic, Rochester. Results: HBO is closely integrated with inpatient practice and includes the same specialty trained clinical team. It is the first point of contact 24/7 for pts and triage evaluations. CAR-T and TCE are given on HBO followed by monitoring per REMS and as clinically needed until admission criteria is met. Remote patient monitoring (RPM) tools were used as part of outpatient monitoring. Out of 169 CAR-T pts, 87 (51%) were dosed with new indication/products (follicular lymphoma, mantle cell lymphoma, myeloma). Among those, 80 (92%) pts were dosed outpatient, among whom 21 (27%) were never hospitalized. CRS and ICANS incidences were comparable to that reported in registration studies. Median time to first admission from CAR-T infusion was 1 day (range, 0-9), with 31% (n=18/59) of admissions after day 3 post infusion. The most common cause of hospitalization was fever (n=40, 59%). Median length of hospital stay was 4 days (range, 1-49). Median time to tocilizumab (n=45, 80%), steroid (n=1, 2%), escalation of oxygen support (n=7, 12%), vasopressor (n=2, 3%), ventilator (n=1, 2%), hemodialysis (n=1, 2%) and ICU transfer (n=3, 5%) was 1 day (range, 0-31) after first admission. Use of bridging therapy, elevated CRP and LDH were predictive of early admission (ROC AUC 0.62). Four pts received teclistamab on HBO and enrolled in RPM. Data from more pts will be reported at ASCO. Conclusions: Our expanded study in CAR-T and TCE confirms that HBO is feasible and that CAR-T and TCE can be safely dosed outpatient. Approximately 31% of pts were admitted after 3 days from CAR-T infusion, and 27% of our pts were never admitted. Variables associated with aggressive disease can predict early hospitalization in pts receiving FDA-approved CAR-T. Extension of HBO practice to TCE is feasible.[Table: see text]

Perceptions of telehealth among inpatient consultative dermatology providers and practice patterns during COVID-19.

Use of inpatient teledermatology increased during the COVID-19 pandemic. We surveyed the Society for Dermatology Hospitalists to better characterize the impact of COVID-19 on teledermatology use by inpatient dermatology providers, particularly on provider perceptions of teledermatology. Prior to the COVID-19 pandemic, 40% (8/20) of surveyed providers had used telehealth at their institution to help perform inpatient consults, while 90% (18/20) adapted use of teledermatology during the pandemic. 80% (16/20) reported that their opinion of teledermatology changed as a result of the COVID-19 pandemic, with the vast majority (87.5%, 14/16) reporting having a more positive opinion. Benefits of teledermatology included efficiency, ability to increase access safely, and ability for clinicians to focus on complex cases. Some providers expressed concerns over the potential implications regarding the perception of dermatology within medicine, limitations of inadequate photos, and breakdowns in communication with consulting teams and patients. Robust algorithms and or utilization criteria of teledermatology may help to mitigate risk, while increasing access to inpatient dermatologic evaluation.

Practices and Policies That Support Breastfeeding Among Military Women: A Systematic Review.

Previous and limited assessments of breastfeeding in women serving on active duty in the U.S. military demonstrate varied and conflicting data regarding breastfeeding outcomes. Disparities exist within the military where enlisted service members have consistently lower rates of breastfeeding duration compared to officers. Yet, little is known about successful care practices and military policies that promote breastfeeding in military women. The aim of this systematic review is to examine care practices and military policies associated with increased breastfeeding initiation and duration among women serving in the U.S. military. We searched Cochrane Database, Cumulative Index of Nursing and Allied Health Literature, PubMed, and PsycInfo for studies published from 2000 to 2022 that included U.S. military personnel and that focused on care practices and military policies that support breastfeeding. Our search terms included (breastfeeding OR breastfeed AND military) and (lactation OR lactating AND military). We included randomized controlled trials, quasi-experimental, cohort, cross-sectional, and other observational designs. We evaluated potential bias in studies using the Evidence Project Risk of Bias Tool and synthesized the overall evidence using the Johns Hopkins Nursing Evidence-Based Practice Synthesis and Recommendations Tool. We included 14 studies that were independently reviewed by two authors. Breastfeeding initiation rates among military women were between 66% and 98%, and breastfeeding duration rates at 6 months ranged from 13% to 62%. In these studies, researchers examined various inpatient care practices (skin-to-skin care, timing of circumcision, and infant baths) (n = 3), care delivered by different types of providers (n = 3), group versus individual prenatal care (n = 2), breastfeeding education (n = 2), length of maternity leave (n = 2), and workplace support (n = 2). Skin-to-skin contact following delivery was positively associated with breastfeeding outcomes. There is insufficient evidence to determine if care by different types of medical providers, different types of prenatal care and education, timing of circumcision or baths, length of maternity leave, and workplace support influence breastfeeding outcomes. Certain perinatal practices designed to encourage early skin-to-skin contact appear to improve breastfeeding initiation and duration among women serving in the U.S. military. However, there is an overall lack of quality evidence supporting effective practices and policies associated with increased breastfeeding initiation and duration in this population. Given the recent movement toward policy changes that support pregnant and postpartum service members across services, more research is needed to determine the impact of these and other practices and policies on breastfeeding rates, specifically among enlisted service members who have demonstrated lower breastfeeding rates than officers.

Respiratory Outcomes for Ventilator-Dependent Children With Bronchopulmonary Dysplasia.

To describe outpatient respiratory outcomes and center-level variability among children with severe bronchopulmonary dysplasia (BPD) who require tracheostomy and long-term mechanical ventilation. Retrospective cohort of subjects with severe BPD, born between 2016 and 2021, who received tracheostomy and were discharged on home ventilator support from 12 tertiary care centers participating in the BPD Collaborative Outpatient Registry. Timing of key respiratory events including time to tracheostomy placement, initial hospital discharge, first outpatient clinic visit, liberation from the ventilator, and decannulation were assessed using Kaplan-Meier analysis. Differences between centers for the timing of events were assessed via log-rank tests. There were 155 patients who met inclusion criteria. Median age at the time of the study was 32 months. The median age of tracheostomy placement was 5 months (48 weeks' postmenstrual age). The median ages of hospital discharge and first respiratory clinic visit were 10 months and 11 months of age, respectively. During the study period, 64% of the subjects were liberated from the ventilator at a median age of 27 months and 32% were decannulated at a median age of 49 months. The median ages for all key events differed significantly by center (P ≤ .001 for all events). There is wide variability in the outpatient respiratory outcomes of ventilator-dependent infants and children with severe BPD. Further studies are needed to identify the factors that contribute to variability in practice among the different BPD outpatient centers, which may include inpatient practices.

Neonatal and Infant-Juvenile Morbidity in African Hospitals: The Case of Commune II of the District of Bamako

Introduction: Neonatal and child morbidity is a threat to socio-economic and health progress in sub-Saharan Africa. In paediatric in-patient practice, knowledge of morbidity is important for health care personnel to ensure optimal patient management. The frequency of these pathologies varies between countries. Objective: The objective of our study was to identify the main morbidities in children hospitalised in the paediatric ward of the commune II health centre. Methods: This was a retrospective descriptive study from 1 January to 31 December 2017. We included all children aged 01 month to 15 years hospitalized in the pediatric ward. The study included 418 children aged 0 to 15 years hospitalised in the department during the study period. Results: Children aged 0 to 5 years were the most represented 89.4% with a majority in the 0 to 1 month age group (39%). Males were the most represented with 58%, i.e. a M/F sex ratio of 1.4. ). The children's mothers were not in school in 78% of cases and were housewives in 70%, and 95% of the parents were married. Socioeconomic status was very low in 34% of families. The patients consulted after 1 to 2 days in 47.1% of cases. Admission to the service was direct in 84% and hospitalisation was more frequent between July and November in 66.3%. The reasons for hospitalization of children were dominated by fever 39% followed by respiratory difficulties 29% and convulsions 10%. Malaria was the first cause of hospitalization with 30%.