Pediatric Ambulatory Research Articles

Population Pharmacokinetics of Casirivimab and Imdevimab in Pediatric and Adult Non-Infected Individuals, Pediatric and Adult Ambulatory or Hospitalized Patients or Household Contacts of Patients Infected with SARS-COV-2.

Casirivimab (CAS) and imdevimab (IMD) are two fully human monoclonal antibodies that bind different epitopes on the receptor binding domain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and block host receptor interactions. CAS + IMD and was developed for the treatment and prevention of SARS-CoV-2 infections. A population pharmacokinetic (PopPK) analysis was conducted using pooled data from 7598 individuals from seven clinical studies to simultaneously fit concentration-time data of CAS and IMD and investigate selected covariates as sources of variability in PK parameters. The dataset comprised CAS + IMD-treated pediatric and adult non-infected individuals, ambulatory or hospitalized patients infected with SARS-CoV-2, or household contacts of patients infected with SARS-CoV-2. CAS and IMD concentration-time data were both appropriately described simultaneously by a two-compartment model with first-order absorption following subcutaneous dose administration and first-order elimination. Clearance estimates of CAS and IMD were 0.193 and 0.236 L/day, respectively. Central volume of distribution estimates were 3.92 and 3.82 L, respectively. Among the covariates identified as significant, body weight and serum albumin had the largest impact (20-34%, and ~ 7-31% change in exposures at extremes, respectively), while all other covariates resulted in small differences in exposures. Application of the PopPK model included simulations to support dose recommendations in pediatrics based on comparable exposures of CAS and IMD between different weight groups in pediatrics and adults following weight-based dosing regimens. This analysis provided important insights to characterize CAS and IMD PK simultaneously in a diverse patient population and informed pediatric dose selection.

Determining infection prevention staffing needs for the pediatric ambulatory and procedural care setting.

Recent analyses suggest thatexisting infection preventionist (IP) staffing ratios do not reflect the scope of institutional needsafter accounting for complexity and non-inpatient locations. We sought to determine the current IP staffing level required to address the complexity and scope of our pediatric ambulatory and procedural operations. This needs assessment was adapted from previous analyses by Bartles et al (2018). We surveyed IPs covering ambulatory/procedural locations regarding clinical complexity indicators and estimated hours per week spent engaged in IP activities. The reported hours were used to calculate total IP hours per week and associated full-time equivalents (FTEs). Half (118/237) of surveyed locations/services reported at least 1 complexity indicator, while nearly 9% (21/237) reported 3 or more complexity indicators. IPs spent 181.0h/wk focused on ambulatory/procedural locations, equating to 4.5 FTEs. Infection prevention and control leadership used these findings to successfully add 4 IP FTEs to the department. These FTEs will allow increased ambulatory/procedural IP support, improved regulatory readiness, and increased quality improvement initiatives. Assessing the complexity and scope of pediatric ambulatory/procedural locations can be a valuable tool for (1) advocating for overall IP staffing increases at a system level and(2) determining the distribution of IP time and resources in such locations.

Utilization and Patient-Reported Outcomes of Direct-to-Consumer Telemedicine During the First 6 Weeks of the COVID-19 Pandemic in the Largest Pediatric Ambulatory Network in New York State.

Objective: We aimed to (1) describe telemedicine utilization and usability during the first 6 weeks of the pandemic and (2) determine if usability varied by individual- or visit-level characteristics. Methods: We conducted a retrospective cohort study of ambulatory pediatric telemedicine visits occurring between March 10, 2020, and April 18, 2020, across a large academic health system. We performed manual chart review to assess individual- and visit-level characteristics and invited caregivers to respond to an adapted Telehealth Usability Questionnaire (TUQ). We used multiple logistic regression to determine predictors of high usability. Results: There were 3,197 ambulatory pediatric telemedicine visits, representing 2,967 unique patients. Patients were racially/ethnically diverse (42.5% non-Hispanic White) and primarily English-speaking (89.2%). Surveys were completed by 441 (17%) of those invited. Every item of the TUQ had agreement or strong agreement from the majority of respondents. Compared with non-Hispanic White, non-Hispanic Asian identity was associated with lower usability in three domains and overall, and non-Hispanic Black identity was associated with higher satisfaction and future use. As compared with caregivers of infants younger than 1 year, caregivers of older patients reported lower usability in the three domains. Conclusions: Telemedicine was successfully implemented across 18 ambulatory pediatric specialties in the largest health system in New York State at the onset of COVID-19, and caregivers found it usable and acceptable. Usability scores did not vary by visit-level characteristics but did vary by race/ethnicity and age. Further research is necessary to identify modifiable drivers of the patient experience, particularly in non-Hispanic Asian communities and older adolescents.

Reclassification of Adolescent Ambulatory Prehypertension and Unclassified Blood Pressures by 2022 American Heart Association Pediatric Ambulatory Blood Pressure Monitoring Guidelines

To describe the epidemiology of reclassification of prehypertensive and unclassified adolescents by 2022 American Heart Association pediatric ambulatory blood pressure monitoring (ABPM) guidelines, and to evaluate the association of the new diagnostic categories with left ventricular hypertrophy (LVH). A single-center, retrospective review of ABPM reports from adolescents 13-21years old, from 2015 through 2022, was performed. Adolescents with prehypertension or unclassified by 2014 guidelines were reclassified by 2022 definitions. Logistic regression models evaluated the association of reclassification phenotypes with LVH. A majority of prehypertensive adolescents reclassified to hypertension (70%, n=49/70). More than one-half (57%, n=28/49) of the hypertension was isolated nocturnal hypertension, and 80% was systolic hypertension. Reclassification to hypertension was more common in males. The majority (55.6%) of unclassified adolescents were reclassified to normotension. No demographic or clinical variables were associated with reclassification categories. LVH was not associated with hypertension in the reclassified prehypertensive or unclassified groups. The 2022 ABPM guidelines clearly define blood pressure phenotypes. However, reclassification to hypertension was not associated with an increased odds of LVH. Because most prehypertensive adolescents reclassified as hypertensive by nighttime BPs alone, this study highlights the lowered threshold for nocturnal hypertension. Prospective studies in larger, well-defined cohorts are needed to describe better the predictive value of 2022 BP phenotypes for target organ damage.

Paper 06: Is There a Home-Field Advantage in Sports Medicine Clinic? Comparing Well-Being Outcomes of Two Staffing Models

Objectives: Learning objectives: Define differences between integrated versus rotating team-based models of care Identify tools to assess professional fulfillment, burnout, and clinical efficiency Understand the impact of integrated versus rotating team-based care models on care team members well-being Project objective/background: Team-based healthcare improves patient access, billable services, and recruitment/retention (1). The staff roles and tasks impacts working to top of license (2) which likely contribute to professional fulfillment and well-being at work. However, well-being measures comparing team-staffing models have not been described. We compare well-being measures of an Integrated Consistent Care-Team Model (ICCM) with Rotating Care-Team Model (RTM) in pediatric sports medicine clinics. Our hypothesis is that ICCM providers and staff would consistently demonstrate greater professional fulfillment, less burnout, greater clinical efficiency, and more advanced team development compared to RTM providers and staff. Methods: We identified an ICCM and RTM model within one healthcare system. The ICCM group includes one core team of pediatric sports medicine providers and staff (n=6), consistently located in the same outpatient practice setting. The RTM includes varying provider and staff team members at varying locations (n=7). All care team members from both models completed three assessments (at 0 and 7 months) of professional fulfillment, burnout, and perception of team development. Metrics used included the Professional Fulfillment Index (PFI), a 16-item survey measuring professional fulfillment and burnout, the Mini-Z_2.0, a 10-item survey measuring burnout via Supportive Work Environment and Practice Efficiency subscales, and the Team Development Measure (TDM), a 31-item survey measuring team development. EMR Data was also analyzed to determine trends in efficiency and practice across the RTM and ICCM groups. Results: PFI results taken at both time periods indicated higher rates of Professional Fulfillment in the ICCM group than the RTM Group. A cutoff point of 3.00 or greater is indicative of professional fulfillment and was demonstrated by the ICCM group at both time points (M=3.31, SD=0.33; M=3.37, SD=0.30). RTM team members scored significantly higher (unfavorable) than ICCM team members on PFI Overall Burnout Scale and showed higher scores in Work Exhaustion and Interpersonal Disengagement subscales. Mini-Z_2.0 results were favorable for ICCM team members on the Supportive Work Environment and Practice Efficiency subscales at both time periods. Overall scaled scores for the ICCM team were greater than the cutoff point of 40 at both time periods, indicating a joyful workplace, in contrast to RTM scores which were below the cutoff points on subscale scores and overall scores at both time periods. ICCM members also trended higher in team development scores on the TDM survey at both time periods. A Welch’s t-test was performed for the Mini-Z and PFI data collection and determined results were statistically significant across both samples and time periods. Furthermore, ICCM providers yielded better EMR efficiency metrics than their RTM colleagues, including less in basket management, PJ time, clinical review and EMR time on unscheduled days at both time periods. Both groups averaged a similar number of appointments per day at each time point (M=9.51 in January; M=11.61 in August). Conclusions: This study describes differences in well-being measures for providers and staff within a pediatric sports medicine ambulatory clinic setting when comparing two different care team models across a 7-month period, suggesting that consistent care-team with core providers and less variability has advantages to provider and staff well-being.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Estimations of Inpatient and Ambulatory Pediatric Tonsillectomy in the United States: A Cross-sectional Analysis.

To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019. Cross-sectional analysis. Healthcare Cost and Utilization Project databases. We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission. An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001). A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk.

Promoting oral and dental health in early childhood - knowledge, views and current practices among paediatricians in Israel.

The aim of this study was to evaluate the knowledge and practice of paediatricians in promoting oral and dental health among young patients (under age 36 months) and their parents. 145 anonymous questionnaires were distributed among paediatricians, 130 of them were 90% or above answered and were suitable for analysis for this study.75% of the questionnaires were distributed during the national convention of the Israeli Association of Clinical Paediatrics, 10% in paediatric ambulatory clinics and 15% in paediatric departments in hospitals. Questionnaires were distributed between 2018 and 2020. The inclusion criteria were physicians specialists in paediatrics or residents in paediatrics, all have Israeli licences to practice in Israel. exclusion criteria were partially filled questionnaires. The questionnaire was validated in a pilot study during the years 2010-2012. In addition to demographic variables that included medical training, post-graduate education and clinical practice the questionnaire included 42 questions. Eleven questions on demographics and amount of dental training during academic and clinical training 31 questions belonged to several sections that referred to the participants' awareness of the AAP guidelines regarding oral and dental health and knowledge of oral health. In each section paediatricians were asked to answer or give an opinion on a specific issue, their answers were coded to scores on a scale of 0-5 and summed per section. Correlations between different variables were analysed. The t-test and Mann-Whitney U test were performed for comparing two variables. For comparing more than two variables, we used the Kruskal-Wallis one-way analysis of variance test or ANOVA. The response rate was 89% (130 questionnaires out of 145). The survey showed that most paediatricians (80%) recognized their role in maintaining the oral and dental health of their young patients. Nevertheless, most admitted that they do not perform simple procedures on a regular basis, like dental examinations (64.6%), or asking parents about feeding habits (59.2%) or teeth brushing (75.4%). Only 21% of the participants expressed adequate knowledge of dental care for children younger than age 3 years. Fifty-eight percent of the participants never had any dental training during their entire paediatric medicine training, including medical school. Paediatricians in private or baby clinics received higher scores in practicing caries prevention, 24.15 ± 5.17 (SD), than paediatricians in hospitals, 2.79 ± 0.54 (SD) (p = 0.006). Caries prevention practice was not found to correlate with paediatricians' knowledge or attitudes regarding oral and dental caries prevention. Oral and dental knowledge should be incorporated into the paediatric medicine curriculum. With their heavy workload, paediatricians generally do not implement dental caries risk assessment and counselling.

170 Misdiagnosis of scabies: How dermoscopy and direct examination can improve scabies diagnosis accuracy

This study aims to report a case of misdiagnosis and delay in the initiation of treatment of a patient with scabies and to emphasize the importance of dermoscopy and direct examination in improving the diagnostic accuracy of scabies. A 2-year-old boy, seen at a pediatric dermatology ambulatory in May 2022, complaining of pruritus for about 2 months. He had been previously diagnosed with dermatophytosis and atopic dermatitis and had been treated for a month with topical moisturizer and antifungal. On examination, diffuse cutaneous xerosis and confluent erythematous papules on the feet were observed. Upon dermoscopic examination of the region, serpiginous tunneling and the delta glider sign at the end of the tunnel were observed between the lesions, which respectively represent the path taken by Sarcoptes scabiei in the epidermis and its anterior portion. Superficial curettage with scalpel blade was performed exactly where the delta glider sign was found, with deposition of the material on a microscope slide with 10% potassium hydroxide. Then direct examination under the optic microscope, revealed the mite, confirming the diagnosis of scabies. We can say that dermoscopy associated with direct examination is a non-invasive, simple and low-cost diagnostic method that allows an accurate diagnosis of this highly contagious dermatosis, which has the potential to cause epidemic outbreaks, and which is still rather neglected.

Differentiating Eosinophilic Esophagitis and Eating/Feeding Disorders.

Eosinophilic esophagitis (EoE) is an inflammatory condition of the esophagus that causes symptoms of esophageal dysmotility. Patients with feeding or eating disorders (ED) can have similar symptoms, and there is a paucity of literature exploring these similarities. Furthermore, EoE can occur in addition to an ED, requiring clinicians to obtain a thorough history, make accurate diagnoses, and adequately treat all underlying conditions. We present 4 pediatric cases highlighting the similarities between EoE and ED symptomatology. Patients 1 to 3 were presumed to have an ED and were subsequently diagnosed with EoE. Patient 4 had a history of previously diagnosed and inadequately treated EoE, but was later found to also have a longstanding ED. The patients presented to the University of Rochester Pediatric Ambulatory Clinics in 2020. This series demonstrates that symptoms of EoE can overlap with those of an ED, such as anorexia nervosa or avoidant restrictive food intake disorder. Therefore, assessment for either EoE or an ED should include questions related to both diagnoses. Symptoms that may raise suspicion of EoE are indigestion, acute (versus chronic) weight loss, and dysphagia, including the inability to swallow pills, particularly in the presence of personal or family history of atopy. Patients with known EoE should be periodically evaluated for the presence of an ED. This case series illustrates that EoE can either present as an ED or complicate the diagnosis and/or treatment of an ED, making prompt diagnosis and treatment essential for successful management of all conditions.

Accuracy of Antibiotic Prescription Dosing for Urinary Tract Infections in a Regional Pediatric Ambulatory Care Setting.

Antibiotics are the most common class of medication prescribed in pediatrics, with the majority of prescriptions occurring in the outpatient setting. Our objective was to evaluate the accuracy of antibiotic dose, frequency, and formulation prescribed for urinary tract infections (UTIs) in the pediatric ambulatory care setting. This was a retrospective review of electronic medical records conducted at 2 suburban pediatric practices in a mid-sized metropolitan region. Encounter-related prescriptions were identified using UTI-associated International Classification of Diseases, 10th Revision codes. Patients aged 2 months through 18 years were included if they had been prescribed an oral antibiotic for the treatment of UTI. Antibiotic dose, frequency, and formulation were considered accurate if consistent with clinical guidelines and tertiary dosing references. Nearly 1 in 4 prescriptions had dosing inaccuracies. The proportion of errors was highest with amoxicillin-clavulanate (75%; 9/12) and amoxicillin (52%; 33/64). The most common reasons for dosing incorrectly were "low dose" or "unnecessarily high dose." Additionally, 55% of the included prescriptions were for oral suspensions, and 1 in 4 of these were dosed incorrectly. Inaccuracies in antibiotic prescribing for pediatric UTI are common, including for frequently prescribed agents and oral formulations. To address these missed opportunities for stewardship in the outpatient setting, key educational sessions with providers should include reviewing optimal antibiotic dosing for uropathogens and highlighting common errors when oral suspensions are prescribed.

Reducing the number of rebooking of urgent in-person visits in general paediatric ambulatory clinics during the COVID-19 pandemic

Background: Due to the COVID-19 pandemic, all out-patients clinics shifted to telehealth visits1. However some patients still needed to be seen as face to face visit2, mostly through the new urgent referrals which were overbooked in the clinics due to the limited availability of slots3. The aim of this quality improvement project was to decrease the percentage of re-booked urgent referrals for in-person visits in the general paediatric clinics from 60% to 30% within 2 months. Methods: An intervention study started in October 2020 until present at the Out-patient Paediatric Department, Hamad General Hospital, Qatar. It included all general paediatric clinics, targeting urgent referrals. The intervention was to standardize the triaging process of urgent referrals (Figure 1) to guide the general paediatric team for booking patients to in-person visits within two weeks. Patients were contacted to confirm the date, time, and location of their visits. Results: A total of 48 overbooking referrals in 11 clinics were screened with an average of 3 patients per clinic. 69% of the referral were re-booked to the next clinics. Implementing the above intervention methods, the number of re-booked urgent referrals went down to 28% (1 patient/clinic) within a 2-month period (Figure 2). Conclusion: During the unprecedented time of the pandemic, patients still need to access healthcare services safely and in a timely manner. This study showed that using a standardized pathway, the target of decreasing the need to re-book urgent visits for in-person evaluations was achieved. Standardization reduces wastes in processes (Figure 1) and decreases variations that may lead to overutilization of the limited resources and negatively affects patient care. Continuous monitoring and evaluation of the outpatient referrals processes are critical in ensuring the delivery of high-quality care.

Pediatric otolaryngology: influence of ambulatorial surgical procedures on postoperative pain

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;In Pediatric Otolaryngology surgery associating procedures is a common finding. Each surgical act elicits different degrees of pain, with implications on recovery. The aim of this work was to evaluate the severity of children's pain after outpatient surgery, considering combinations of common Otolaryngologic procedures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;Data from children submitted to surgery in the Pediatric ambulatory Unit of Centro Hospitalar Universitário do Porto was reviewed. Children with history of previous interventions or any associated comorbidity were excluded. Postoperative pain at hospital discharge using the Universal Pain assessment tool (0-10) was assessed and compared concerning the various procedures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 954 operated children were included. Adenoidectomy was performed in 783 patients (82.1%), tonsillectomy in 714 (74.8%), myringotomy in 432 (45.3%) and radiofrequency inferior turbinoplasty in 98 (10.3%). Patients undergoing tonsillectomy showed significantly higher pain scores (1.48±1.02 in tonsillectomy versus 0.89±0.75 in no tonsillectomy, p=0.001). Importantly, adenoid curettage, radiofrequency inferior turbinoplasty and myringotomy did not associate with increased post-operative pain (p&amp;gt;0.05). Number of procedures within the same intervention and surgical indication (recurrent infections, obstructive sleep disordered breathing and otitis media with effusion) did not influence post-operative pain scores (p&amp;gt;0.05).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Performing total tonsillectomy was the most important influencer of post-operative pain in Pediatric ambulatory surgery in this cohort. Performing concomitant adenoidectomy, turbinoplasty or miringotomy do not seem to influence post-operative pain significantly. A higher number of procedures within the same intervention does not associate directly with postoperative pain scores.&lt;/p&gt;

Discordances between pediatric and adult thresholds in the diagnosis of hypertension in adolescents with CKD

BackgroundAdolescents with chronic kidney disease (CKD) are a unique population with a high prevalence of hypertension. Management of hypertension during the transition from adolescence to adulthood can be challenging given differences in normative blood pressure values in adolescents compared with adults.MethodsIn this retrospective analysis of the Chronic Kidney Disease in Children Cohort Study, we compared pediatric versus adult definitions of ambulatory- and clinic-diagnosed hypertension in their ability to discriminate risk for left ventricular hypertrophy (LVH) and kidney failure using logistic and Cox models, respectively.ResultsOverall, among 363 adolescents included for study, the prevalence of systolic hypertension was 27%, 44%, 12%, and 9% based on pediatric ambulatory, adult ambulatory, pediatric clinic, and adult clinic definitions, respectively. All definitions of hypertension were statistically significantly associated with LVH except for the adult ambulatory definition. Presence of ambulatory hypertension was associated with 2.6 times higher odds of LVH using pediatric definitions (95% CI 1.4–5.1) compared to 1.4 times higher odds using adult definitions (95% CI 0.8–3.0). The c-statistics for discrimination of LVH was statistically significantly higher for the pediatric definition of ambulatory hypertension (c=0.61) compared to the adult ambulatory definition (c=0.54), and the Akaike Information Criterion was lower for the pediatric definition. All definitions were associated with progression to kidney failure.ConclusionOverall, there was not a substantial difference in pediatric versus adult definitions of hypertension in predicting kidney outcomes, but there was slightly better risk discrimination of the risk of LVH with the pediatric definition of ambulatory hypertension.Graphical abstract

How much time do doctors spend providing care to each child in the ED? A time and motion study

BackgroundThe total time per patient doctors spend providing care in emergency departments (EDs) has implications for the development of evidence-based ED staffing models. We sought to measure the total time...

Comparison of active versus passive surveillance adverse event reporting in a paediatric ambulatory chiropractic care setting: a cluster randomised controlled trial

ObjectivesThis pragmatic, cluster, stratified randomised controlled trial (RCT) compared the quantity and quality of adverse event (AE) reports after chiropractic manual therapy in children less than 14 years of age,...

State of the art in clinical decision support applications in pediatric perioperative medicine.

The goal of this review is to describe the recent improvements in clinical decision tools applied to the increasingly large and complex datasets in the pediatric ambulatory and inpatient setting. Clinical decision support has evolved beyond simple static alerts to complex dynamic alerts for: diagnosis, medical decision-making, monitoring of physiological, laboratory, and pharmacologic inputs, and adherence to institutional and national guidelines for both the patient and the healthcare team. Artificial intelligence and machine learning have enabled advances in predicting outcomes, such as sepsis and early deterioration, and assisting in procedural technique. With more than a decade of electronic medical data generation, clinical decision support tools have begun to evolve into more sophisticated and complex algorithms capable of transforming large datasets into succinct, timely, and pertinent summaries for treatment and management of pediatric patients. Future developments will need to leverage patient-generated health data, integrated device data, and provider-entered data to complete the continuum of patient care and will likely demonstrate improvements in patient outcomes.

MON-312 EVALUATION OF CHOLESTEROL AND TRIGLYCERIDES SERUM LEVELS IN PATIENTS ATTENDING TO A PEDIATRIC NEPHROLOGY AMBULATORY AT A SANTOS REFERENCE HOSPITAL

The high concentration of cholesterol and triglycerides are a risk factor for several diseases, especially vascular diseases. However, its role in the evolution of renal disease is still unclear. Therefore, the objective of the study is to analyze the cholesterol and triglyceride levels of children with renal disease, that attend a pediatric nephrology ambulatory, and to establish their role in the progression of the disease, given its cumulative effect.

Acute In Vivo Evaluation of the Pittsburgh Pediatric Ambulatory Lung.

Respiratory failure is a significant problem within the pediatric population. A means of respiratory support that readily allows ambulation could improve treatment. The Pittsburgh Pediatric Ambulatory Lung (P-PAL) is being developed as a wearable pediatric pump-lung for long-term respiratory support and has previously demonstrated positive benchtop results. This study aimed to evaluate acute (4-6 hours) in vivo P-PAL performance, as well as develop an optimal implant strategy for future long-term studies. The P-PAL was connected to healthy sheep (n = 6, 23-32 kg) via cannulation of the right atrium and pulmonary artery. Plasma-free hemoglobin (PfHb) and animal hemodynamics were measured throughout the study. Oxygen transfer rates were measured at blood flows of 1-2.5 L/min. All animals survived the complete study duration with no device exchanges. Flow limitation because of venous cannula occlusion occurred in trial 2 and was remedied via an altered cannulation approach. Blood exiting the P-PAL had 100% oxygen saturation with the exception of trial 4 during which inadequate device priming led to intrabundle clot formation. Plasma-free hemoglobin remained low (<20 mg/dl) for all trials. In conclusion, this study demonstrated successful performance of the P-PAL in an acute setting and established the necessary methods for future long-term evaluation.

Let Them Speak for Themselves: Improving Adolescent Self-Report Rate on Pre-Visit Screening

BackgroundAdolescent pre-visit screening on patient-generated health data is a common and efficient practice to guide clinical decision making. However, proxy informants (eg, parents or caregivers) often complete these forms, which may lead to incorrect information or lack of confidentiality. Our objective was to improve the adolescent self-report rate on pre-visit screening. MethodsWe conducted an interventional study using an interrupted time series design to compare adolescent self-report rates (percent of adolescents ages 12−18 years completing their own pre-visit screening) over 16 months in general pediatric ambulatory clinics. We collected data using a computerized clinical decision support system with waiting room electronic tablet screening. Preintervention rates were low, and we created and implemented 2 electronic workflow alerts, one each to the patient/caregiver and clinical staff, reminding them that the adolescent should answer the questions independently. We included the first encounter from each adolescent and evaluated changes in adolescent self-reporting between pre- and postintervention periods using interrupted time series analysis. ResultsPatients or caregivers completed 2670 qualifying pre-visit screenings across 19 preintervention, 7 intervention, and 44 postintervention weeks. Self-reporting by younger adolescents nearly doubled, with a significant increase of 19.3 percentage points (confidence interval [CI], 9.1−29.5) from the baseline 20.5%. Among older adolescents, the stable baseline rate of 53.6% increased by 9.2 absolute percentage points (CI, −7.0 to 25.3). There were no significant pre- or postintervention secular trends. ConclusionsTwo automated alerts directing clinic personnel and families to have adolescents self-report significantly and sustainably improved younger adolescent self-reporting on electronic patient-generated health data instruments.