Tertiary Care Children's Hospital Research Articles

Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals

To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatumat tertiary care children's hospitals. We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. In total, 7183 patients with an average age of 15.2years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons. Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Impact of the Coronavirus (COVID-19) Pandemic on the Care of Pediatric Acute Appendicitis.

Appendicitis is the most common abdominal surgical emergency in children. With the rise of the Coronavirus-19 pandemic, quarantine measures have been enforced to limit the viral transmission of this disease. The purpose of this study was to identify differences in the clinical presentation and outcomes of pediatric acute appendicitis during the Coronavirus-19 pandemic. A single-institution retrospective assessment of all pediatric patients (<18years old) with acute appendicitis from December 2019 to June 2020 was performed at a tertiary care children's hospital. Patients were divided into two groups: (1) the Pre-COVID group presented on or before March 15, 2020, and (2) the COVID group presented after March 15, 2020. Demographic, preoperative, and clinical outcomes data were analyzed. 45 patients were included with a median age of 13years [IQR 9.9 - 16.2] and 35 males (78%). 28 patients were in the Pre-COVID group (62%) and 17 in the COVID group (38%). There were no differences in demographics or use of diagnostic imaging. The COVID group did have a significantly delayed presentation from symptom onset (36 vs 24hours, P < .05), higher Pediatric Appendicitis Scores (8 vs 6, P = .003), and longer hospital stays (2.2 vs 1.3days, P = .04). There were no significant differences for rates of re-admission, re-operation, surgical site infection, perforation, or abscess formation. During the Coronavirus-19 pandemic, the incidence of pediatric acute appendicitis was approximately 40% lower. These children presented in a delayed fashion with longer hospital stays. No differences were noted for postoperative complications.

The hidden burden of eating disorders during the COVID-19 pandemic

The hidden burden of eating disorders during the COVID-19 pandemic

Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers

Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be managed via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture characteristics associated with successful reduction by ED physicians. We conducted a retrospective study of children (aged <18 years) presenting to the ED of a tertiary care children's hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphology, management, and complications. Successful ED physician reduction was based on predefined criteria. Orthopedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction. A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to reduce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups. In this series, fractures most amenable to reduction by ED clinicians include distal greenstick fractures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

Changes in Pediatric Faculty Burnout During the COVID-19 Pandemic.

To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated workflow changes, such as deployment on pediatric faculty burnout in an early epicenter of the pandemic. We hypothesized burnout would increase during the COVID-19 surge. We conducted serial cross-sectional surveys of pediatric faculty at an academic, tertiary-care children's hospital that experienced a COVID-19 surge in the Northeastern United States. Surveys were administered pre-surge (February 2020), during the surge (April 2020), and postsurge (September 2020). The primary outcome was burnout prevalence. We also measured areas of worklife scores. We compared responses between all 3 survey periods. Continuous variables were analyzed by using Student's t or Mann-Whitney tests, and categorical variables were analyzed by using χ2 or Fisher's exact test, as appropriate. Our response rate was 89 of 223 (40%) presurge, 100 of 267 (37%) during the surge, and 113 of 275 (41%) postsurge. There were no differences in demographics, including sex, race, and academic rank between survey periods. Frequency of burnout was similar in all 3 periods (20% to 26%). The mean scores of emotional exhaustion improved during the surge (2.25 to 1.9; P = .04). Contrary to our hypothesis, we found no changes in pediatric faculty burnout after a COVID-19 surge. Emotional exhaustion improved during the COVID-19 surge. However, these findings represent short-term responses to the COVID-19 surge. Longer-term monitoring of the impact of the COVID-19 surge on pediatric faculty burnout may be necessary for health care organizations to mitigate burnout.

Risk factors for subsequent stone events in pediatric nephrolithiasis: A multi-institutional analysis

Children with nephrolithiasis have a 50% risk of recurrence 3 years following an index urinary stone event. The American Urological Association guidelines for medical management of nephrolithiasis suggest metabolic evaluations be stratified according to risk of future stone events. However, no such risk stratification exists across the pediatric population with urinary stone disease. We aim to assess the risk factors among pediatric patients for a subsequent stone event (SSE). A retrospective review for children <17 years of age with a diagnosis of nephrolithiasis and at least one completed follow-up at two tertiary-care children's hospitals within our state between 2012 and 2017 was performed. Children with known monogenic stone disease were excluded as well as those with follow-up less than 1 year. SSEs following initial diagnosis and treatment for nephrolithiasis were defined as follows: subsequent surgical intervention, new stone on imaging, reported stone passage, or ED evaluation for renal colic. Clinical and demographic factors were compared between patients with and without SSEs and analyzed using univariate and multivariate analyses via Cox proportional hazard models. Survival curves for significant associations for SSEs were generated and evaluated using Log-Rank and Wilcoxon comparisons. A total of 200 patients with median clinical follow-up of 2.9 years were analyzed. Median age was 11.5 years (IQR: 6.0-15.5), with 109 (54.5%) males and 91 (45.5%) females, 94 (47%) of whom had a relevant comorbidity. An SSE occurred in 82 patients (41.0%). Age >12 (HR 2.21, 95%CI 1.42-3.45), reported stone event prior to enrollment encounter (i.e. personal history of nephrolithiasis) (HR 1.82, 95%CI 1.14-2.89), and family history of nephrolithiasis (HR 1.62, 95%CI 1.05-2.51) were associated with SSE on univariate analysis while age >12 (HR 2.09, 95%CI 1.33-3.27) and personal history of nephrolithiasis (HR 1.63, 1.02-2.6) retained significance on multivariable analysis. Survival analysis shows increased risk of recurrence with accumulation of risk factors (Summary Figure). Sensitivity analysis accounting for missing family history data retained significance for all three variables. Adolescent age and a personal history of nephrolithiasis are independent risk factors for SSE in children. Understanding these risk factors and the nature of SSE among the pediatric population can potentially enhance counseling for further metabolic work-up and tailored clinical follow-up.

Pediatric Autoimmune Encephalitis in Sri Lanka: A Single-Center Experience over 7 Years

AbstractPediatric autoimmune encephalitis (AE) remains a diagnostic and therapeutic challenge in resource-poor settings. Minimizing delay in diagnosis and appropriate escalation of treatment will help reduce both the short- and long-term neurodisabilities. A retrospective observational study was performed on children consecutively diagnosed with possible AE and then prospectively followed up in a single tertiary care children's hospital in Sri Lanka. Serum and cerebrospinal fluid were tested for neuroglial surface-binding autoantibodies using cell-based assays in majority of these children. Twenty-five children (mean age 7.6 years, standard deviation = 4) were recruited. In these children, presenting symptom was psychiatric in 11 children (44%), seizures in 10 (40%), language regression in 2 (8%), and combination of psychosis and convulsions in 2 (8%). Psychiatric presentations were more common in older (&gt;6 years) compared with young children (p = 0.001), while neurological presentations were more common in children aged ≤6 years (p = 0.001). N-methyl-D-aspartate receptor (NMDAR) antibodies were detected in 9 (45%) and unspecified voltage-gated potassium channel antibodies in 1 (5%) of the 20 tested. All received intravenous steroids and immunoglobulins; 19 (76%) plasma exchange; 7 (29%) rituximab. Complete/substantial improvement at 3 months occurred in 64%. Pediatric Cerebral Performance Category score at last review was 1 (normal function for age) in 43%. Higher proportion of younger children required less intense therapy and had better recovery (56%). Death (8%), incomplete recovery (71%), and relapses (8%) were more in older children. Clinical presentation and disease outcomes were different in children aged &lt;6 years compared with older age group. NMDAR antibody encephalitis was the commonest AE syndrome identified in this cohort.

Flexible Fibreoptic Bronchoscopy Performed Through a Laryngeal Mask Airway (FFB-LMA) in a Paediatric Population: Experience of a Tertiary Care Children's Hospital in Sri Lanka

Studies suggest that flexible fibreoptic bronchoscopy, when performed through a laryngeal mask airway (FFB-LMA), have fewer rates of complications and better efficacy. In comparison to rigid bronchoscopy, FFB is safer for the operator, as it prevents direct exposure to respiratory tract infections such as Covid-19. Airway maintenance with LMA is uncommon when performing FFB in Sri Lanka. This study aimed to report the efficacy and peri-procedural complications of FFB performed through LMA at a tertiary care children's hospital in Sri Lanka. Data were retrieved retrospectively from anaesthetic charts and bed head tickets of all the patients who underwent FFBs performed through LMA at the Sirimavo Bandaranayake Specialized Children's Hospital, Peradeniya. Collected data included age, gender, indication, duration of the procedure, bronchoscopy findings, and complications, if any. Of the total of 176 patients, the majority were infants and between 1-5 years (33.52% each). The most common indication was recurrent/persistent respiratory tract infections (57.9%) followed by foreign body aspirations (21.6%). Clinically significant abnormalities were detected in 87% of the cases. The success rate of extraction of positively identified foreign bodies was 100%. Perioperative complications were observed in 4.5% of the patients. Risk factor analysis, based on multivariate logistic regression, identified the duration of the procedure as a risk factor for complications (OR= 15.57, p = 0.0011). FFB performed through LMA has good efficacy and low complication profile in the studied patient sample.

Infantile Systemic Hyalinosis Presenting as Pseudo-Paralysis in Infancy: Study of Six Cases.

Infantile systemic hyalinosis is a very rare fatal autosomal recessive genetic disorder with a mutation in capillary morphogenesis gene-2- CMG2 /Human anthrax toxin-2 ANTXR2 resulting in spindle cell proliferation, altered collagen metabolism along with extensive deposition of hyaline material in the skin and several tissues. To date only a few cases have been reported in the literature, hence we reported this series. This study is a retrospective chart review of infants diagnosed with infantile systemic hyalinosis from January 2015 through December 2020 at a tertiary care children's hospital in South India. The mean age of presentation was 9.4 months, with a male to female ratio of 1:5. All children were born of consanguineous marriage except one child. All children had symptoms at birth, painful limb movements, multiple joint stiffness, gingival thickening, skin lesions around perianal, perioral areas, and frog-like position. Three (50%) children had stiff skin. Routine tests including complete blood count, liver function test, renal function test, creatine phosphokinase, nerve conduction studies, and metabolic tests were normal in all children. Skin biopsy showed hyalinized collagenous tissue in the dermis. Genetic study results of two cases revealed pathogenic variants in ANTXR2 gene. Infantile systemic hyalinosis should be considered in infants presenting with painful limb movements. The diagnosis helped in avoiding unnecessary investigations and prognostications. The genetic information from proband mutation helped in prenatal diagnosis in two families.

An Analysis of Immature Platelet Fraction Values

IntroductionImmune thrombocytopenia (ITP) in children typically manifests with acute, severe thrombocytopenia leading to variable mucocutaneous and tissue bleeding. Despite gaining insight into disease biology, there is no confirmatory diagnostic test, leaving the clinician to exclude other causes of thrombocytopenia through clinical and laboratory findings. The immature platelet fraction (IPF) is determined by hematologic analyzers via platelet size and RNA content and serves as a measure of bone marrow thrombocyte production. A higher value indicates increased thrombopoiesis. While data exists regarding the validity of IPF as a diagnostic tool for differentiating hypo-productive and consumptive etiologies of thrombocytopenia in the adult population, there is a paucity of data regarding its use in the pediatric population.ObjectivesThis study set out to determine how the IPF value may be utilized to support the diagnosis of ITP among pediatric patients.MethodsThis is a retrospective cohort study at a single tertiary care children's hospital. The electronic medical record (EMR) system was reviewed to include all patients who had an IPF resulted from January 1, 2016 through December 31, 2021. The investigators utilized REDCap ® (Research Electronic Data Capture) to create a database of pediatric patients with thrombocytopenia including their laboratory findings and final diagnoses.Patients were classified as either ITP or non-ITP. Characteristics of ITP and non-ITP cohorts were compared using Wilcoxon rank sum test and Pearson Chi-square test. An ROC-AUC analysis was conducted to identify the IPF value which best predicted if the patient had ITP or not with a 95% confidence interval (CI). The optimal cutoff value was estimated using Youden's index. Sensitivity and specificity were estimated for the cutoff value. Univariable logistic regression was then used to estimate associations between patient characteristics and diagnosis of ITP. Multivariable logistic regression was used to estimate the association between binary IPF and ITP adjusting for other predictors. Statistical significance was assessed at the 0.05 level.ResultsDemographics shown in Table 1 are stratified by patients who had their IPF within 30 days of diagnosis of thrombocytopenia and those who did not. The IPF was significantly higher at presentation in all patients with ITP than patients without ITP (median IPF 12.8% vs 10.5%, P=0.018). An optimal IPF cutoff point for ITP vs. not ITP among all patients was determined to be 5.4% with a sensitivity of 0.85, specificity of 0.39, and AUC of 0.623 (95% CI: 0.527, 0.718). The platelet count for patients with ITP was significantly lower at presentation than in patients without ITP (median 16 x 10 9/L vs 86 x 10 9/L, P<0.001). Logistic regression modeling using IPF as a binary variable, either >5.4% or not, showed that IPF >5.4% is significantly associated with ITP (P<0.001). Platelet count at presentation was also significantly associated with a diagnosis of ITP (P<0.001) and a single unit increase in platelet count decreased odds of ITP by a factor 0.98 (95% CI: 0.97, 0.99). After adjusting for platelet count, IPF >5.4% was still significantly associated with ITP (P=0.003). Those with an IPF >5.4% were 3.34 times more likely to have ITP than non-ITP (95% CI: 1.49, 7.31).When the population was adjusted to include only patients with a platelet count of <100 x 10 9/L at presentation and those that had an IPF obtained within 30 days, the optimal cutoff point for IPF was 15% with a sensitivity of 0.46, specificity of 0.80 and AUC of 0.58 (95% CI: 0.458, 0.719).ConclusionThe data demonstrates that in thrombocytopenic patients, a high IPF (>5.4%) is associated with ITP, but the sensitivity for predicting ITP is low. [Display omitted] DisclosuresDespotovic: Apellis: Consultancy; Agios: Consultancy; Novartis: Consultancy, Research Funding; UpToDate: Patents & Royalties: Royalties. Kirk: Biomarin: Honoraria.

Use of a Sterile Collection Process to Reduce Contaminated Peripheral Blood Cultures.

Contaminated blood cultures pose a significant burden by subjecting children to unnecessary testing, procedures, and antibiotics and increasing health care costs. The aim of our quality improvement (QI) initiative was to decrease the percentage of contaminated peripheral blood cultures in our pediatric emergency department (ED) from an average of 6.7% to <3% over a 16-month period. The QI initiative was implemented in the pediatric ED of a tertiary care children's hospital. Interventions included change of the peripheral blood culture collection from a clean to a sterile process, nursing education, and individualized feedback. The primary outcome measure was the percentage of contaminated peripheral blood cultures. The process measure was the percentage of nurses who completed 75% to 100% of the steps of the sterile collection process, as measured by self-reporting in audit cards. The balancing measures were time from antibiotic ordering to time of administration and ED length of stay. We decreased the percentage of contaminated peripheral blood cultures threefold from a baseline (June 2, 2018, to December 31, 2018) of 6.7% to 2.1% during the intervention period (January 1, 2019, to April 30, 2020). Ninety-eight percent of nurses who completed audit cards reported performing 75% to 100% of the steps of the new sterile process. There was no significant difference in the average time from antibiotic ordering to antibiotic administration or ED length of stay between the baseline and intervention periods. Use of a sterile blood culture collection process, in addition to nursing education and individualized feedback, is an effective method to decrease peripheral blood culture contamination rates in a pediatric ED.

Reporting of Unsafe Conditions at an Academic Women and Children's Hospital.

Unsafe conditions (UCs) are circumstances that increase the probability of a patient safety event occurring. Each UC identified presents an opportunity to prevent a near miss or adverse patient event through proactive mitigation. The aim of this study was to describe the frequency, characteristics, contributing factors, and potential for harm of reported UCs. This is a retrospective descriptive analysis of UC incident reports voluntarily entered into an electronic medical event reporting system at a single tertiary care women and children's hospital. Reports were reviewed and categorized using a previously published classification scheme and a modified Healthcare Failure Mode and Effects Analysis (HFMEA). Reporter role, hospital location, and time to incident resolution were also described. Between July 1, 2016, and June 30, 2019, 348 UCs were entered, representing 3.4% of all reports. Predominant categories of UCs were equipment (43.7%), medication (20.7%), and environmental safety (14.4%). A contributing factor was identified for >99.4% of all UCs, with 77.6% having more than one. Nurses (70.1%) submitted the highest numbers of UCs. The majority of UCs were of mild severity (79.9%) but had the potential to recur frequently (73.3%). UCs represented a small proportion of all reported events across the hospital. Equipment and medication issues were important causes of UCs, and most UCs had one or more contributing factors. Though most UCs were of mild severity, they had a predicted potential to recur frequently, representing significant opportunities for improvement.

Pediatric Tracheostomy Care Simulation: Real-Life Scenarios in a Safe Learning Environment.

Pediatric patients require tracheostomy tube placement as a last resort for critical airway management. Around-the-clock care is needed at discharge because of the high risk of morbidity and mortality associated with a tracheostomy. The potential for catastrophic sequalae can create a high stress home environment. A simulation program that used a high-fidelity manikin was implemented to reduce complications, morbidity and mortality, and improve skills for real-life medical scenarios. A tracheostomy care simulation program was implemented at a large tertiary care children's hospital from October 2019 to October 2020. Caregivers participated in a pre-post program survey and rated 9 statements on a 5-point scale with regard to knowledge, confidence, and comfort level of taking care of their child at home. Emergency scenarios included accidental tracheostomy tube dislodgement, tracheostomy tube plugging, cardiac arrest, and ventilator failure. Classes were recorded for objective start-to-finish scenario time stamps and prompt rates. A medical chart review was performed 90 d after discharge. Eighteen caregivers for 10 children participated. For the 10 children, there was a 9.1% increase in the average total score agreement from pre to post survey, with scores going from "agree" to "strongly agree" (P = .001). Each subset of questions had a significant increase in scores after participation: knowledge, P = .002; confidence, P = .006; and comfort, P = .01. The caregivers required an average 20% prompt rate for the next step in the scenario. Children were 70% female, 80% white, and 60% had public insurance and had their tracheostomy tube placed at a median age of 4 months (range, 0 months to 24 years). Three children (n = 3/9 [33.3%]) were readmitted for tracheitis within 90 d after being discharged to home. Caregiver knowledge, confidence, and comfort levels were increased after participation. Pediatric patients with a tracheostomy are medically fragile, therefore, it is important for caregivers to be aware of and prepared for common tracheostomy emergencies and to "experience" emergency situations firsthand.

Chronic Lymphocytic Thyroiditis and Aggressiveness of Pediatric Differentiated Thyroid Cancer.

Hashimoto's Thyroiditis (HT) is a common cause of hypothyroidism. Among adults with differentiated thyroid cancer (DTC), HT appears to be associated with less severe disease burden. In the absence of information regarding HT and disease burden among children with DTC, we assessed the relationship between pediatric DTC severity and HT. Retrospective cohort. Charts from 90 pediatric patients who underwent surgical removal of DTC from 2002 to 2017 at tertiary-care children's hospital were reviewed. Demographic, clinical, surgical, pathology, and outcome details were compared between patients with and without HT. Consistency among diagnostic modalities of HT was also evaluated. Median age at presentation was 16.0 years (range 4.2-18.9 years). Twenty-two patients were male (24%). Forty-five patients (50%) had HT based on presence of thyroid autoantibodies and/or surgical pathology findings and 45 patients did not have HT. Patients with HT had increased odds of microcalcifications (odds ratio [OR]: 3.01, P=.031) and decreased odds of palpable nodules (OR: 0.212, P=.024) and T2 lesions (vs. T1) (OR: 0.261, P=.015) compared with non-HT. No significant differences in demographics and the incidence of multifocality, extrathyroidal extension, lymphovascular invasion, lymph node or pulmonary metastases, disease recurrence, or radioactive iodine treatment were found between the two groups. Thyroglobulin/thyroid peroxidase autoantibodies and surgical pathology indicative of HT were concordant in 82.4% (κ=0.635, P < .001). HT was present in 50% of children with DTC. Patients with DTC and HT presented with smaller tumors compared to non-HT patients. No significant differences in other markers of disease aggressiveness were found between the two groups. 3 Laryngoscope, 132:1668-1674, 2022.

Variation in Treatment of Children Hospitalized With New-Onset Systemic Juvenile Idiopathic Arthritis in the US.

Increasing evidence supports the conclusion that early initiation of biologics may dramatically improve disease course and reduce glucocorticoid exposure for children with systemic juvenile idiopathic arthritis (JIA). The present study was undertaken to characterize variation in the use of first-line biologic and glucocorticoid therapy and to identify drivers of variation in children hospitalized with new-onset systemic JIA. We conducted a retrospective cohort study of children hospitalized with new-onset systemic JIA from 2008 to 2019 utilizing a comparative pediatric database from 52 tertiary care children's hospitals. Subjects and treatment receipt were identified using International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 discharge diagnosis codes, pharmacy billing data, and clinical transaction classification codes. Mixed-effects logistic regression was used to identify patient- and hospital-level factors associated with receipt of glucocorticoids and biologics. In total, 534 children with new-onset systemic JIA hospitalized during the study period met inclusion criteria. Twenty-nine percent received biologics, and 58% received glucocorticoids. Biologic use increased over time (P < 0.001), methotrexate use decreased (P < 0.01), and glucocorticoid use remained unchanged. Biologics and glucocorticoid use varied significantly between hospitals. High annual hospital volume, intensive care unit stay, and later discharge year were significantly associated with biologic exposure. Medium-high and high annual hospital volume were significantly associated with less glucocorticoid exposure. Despite increasing evidence demonstrating improved outcomes with first-line treatment with biologics, we found significant treatment variation across hospitals with many children not receiving biologics and a persistent high rate of glucocorticoid exposure. These results underscore the need for comparative efficacy studies and improved treatment standardization.

Hospital readmissions at a tertiary care children's hospital: Prevalence, associated characteristics, and preventability.

Hospital readmissions in pediatrics are a severe, potentially avoidable problem of health systems. In our setting, there is little information about this topic. To estimate the rate of readmissions, the proportion of potentially preventable readmissions, and their associated characteristics. Cross-sectional study including hospital readmissions of patients aged 0-18 years, admitted to a tertiary care children's hospital between January 1st and December 31st, 2018. Readmissions were assessed as potentially preventable based on whether they were or not related to the previous admission. Out of 8228 hospital admissions recorded in the study period, the rate of readmissions for any cause was 10 % at 30 days and 7.1 % at 15 days. The proportion of readmissions classified as potentially preventable was 47.9 % at 30 days and 47.5 % at 15 days. No statistically significant differences were observed between readmissions at 30 and 15 days in terms of patient age, health insurance, presence of chronic disease or cause of readmission. The rate of hospital readmissions was 10 % at 30 days and 7.1 % at 15 days of discharge; almost half of them were considered potentially preventable.

Do We Know Where They Go? Obtaining Travel History in Pediatric Patients.

To determine how often travel histories are obtained in pediatric patients. A retrospective medical record review was performed at a single tertiary care children's hospital for patients aged 2 months to 18 years who were admitted October 2015-December 2017 with International Classification of Diseases, 10th Revision codes for potential travel-related illnesses. Demographic information and travel history documentation were obtained, along with travel-related testing. From May to June 2018, prospective, single-blinded, direct observation of a convenience sample of pediatric residents was performed during the initial patient encounter to determine the frequency and quality of travel histories obtained regardless of documentation. Of 249 charts reviewed, 27 (10.8%) patients had a travel history query documented. Patients with complex chronic conditions were significantly less likely to have a travel history documented (37% vs 67%; P = 0.005). Age, sex, length of stay, race, payer status, and critical care admission did not significantly differ between groups. Those with a travel history documented were more likely to have a documented exposure history (100% vs 52%; P < 0.001) and additional testing performed (56% vs 13%, P < 0.001). During this time, a simulation course with residents featuring travel-related diagnoses led to a significant increase in documented travel histories (5% prior versus 21% after, P = 0.03). A total of 37 patient encounters were observed; travel history was asked for 4 times (4/37, 10.8%). Travel histories are rarely asked for in pediatric patients. Missed diagnoses may not only affect the patient but also have broader public health implications. Simulation is an effective tool to improve history-taking skills, yet more work is still needed.

Smoke Exposure Disclosure: Parental Perspectives of Screening in the Inpatient Setting.

Current screening questions for pediatric tobacco smoke exposure are suboptimal. Factors influencing screening accuracy, particularly in the pediatric inpatient setting, are unknown. Our objective was to identify facilitators of and barriers to parental disclosure of smoke exposure when screened during their child's hospitalization and strategies to promote accurate disclosure. This qualitative study was conducted with a convenience sample of parents of children admitted to the medical and surgical unit of a Midwest tertiary care children's hospital. Eligible parents included those with documented disclosure of smoke exposure in the child's electronic health record. A researcher trained in qualitative methods conducted semistructured, in-depth interviews with parents regarding their experiences with smoke exposure screening in the inpatient pediatric setting. Two researchers independently identified concepts directed at barriers, facilitators, and strategies for effective screening, which were compared and reconciled by a third researcher. Facilitators of disclosing their child's smoke exposure included the following: (1) the caregiver's internal characteristic(s) promoting disclosure, (2) perceived relevance of the screening question to the child's health, and (3) the questioner being viewed positively. Barriers included the following: (1) fear of negative consequences, (2) a vague question, (3) lack of knowledge, (4) guilt, and (5) unconducive environment and timing. The strategies parents suggested to improve screening for smoke exposure included the following: (1) communicate preemptively, (2) provide specific exposure examples, (3) improve questioner-caregiver rapport, and (4) improve screening environment and timing. Parents identified various mechanisms to improve tobacco smoke exposure screening. The facilitators, barriers, and strategies provide opportunities to improve the inpatient pediatric screening process.

Outpatient Follow-up Care After Hospital Discharge of Children With Complex Chronic Conditions at a Rural Tertiary Care Hospital.

To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge. We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children's hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded. Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission (P = .020) and prolonged length of stay (P = .004) were associated with decreased likelihood of completing recommended follow-up. Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.

Services Delivered by the Department of Paediatric Neuroscienc at Walk- in Clinic: A Study in Tertiary Care Children Hospital in Bangladesh

Introduction: Outpatient services usually cost less, because you don't need to stay overnight. Staff members at outpatient centers are well trained in the service they provide. Neurodevelopmental Disorders (NDDs) are a heterogeneous group of conditions that share a commonality of abnormal development and functioning of the brain. Paediatric Neurscience Department of Dhaka Shishu Hospiatal provides outpatient services for the children having neurodevelopmental problem without an overnight stay. Aim of the study: The aim of the study was to evaluate the clinical patterns of neurological and neurodevelopmental disorders of children attending in the OPD in the clinic. Materials and methodology: This retrospective study was conducted in the Outpatient department of Neuroscience Department of Dhaka Shishu (Children) Hospital where a multi-disciplinary team comprising a physician, developmental therapist and child psychologist used to give service. Patients were contacted in Outpatient department of Neuroscience Department who were enrolled in OPD registration from March’2019 to August’2019. A total 3632 out patients were selected for the study. Data were organized and prepared on a spreadsheet. All statistical tests were run on SPSS for Windows version 16.0 software. Results: Total 3632 patients attended the OPD clinic. Nine hundred and two (902) patients were referred to other clinics. Most of the patients (400) were referred for general assessment and ( 400) mental health clinic, Ninety (90) for psychological assessment, Seventy nine(79)for admission, Seventy one (71) to SAHIC for hearing assessment and the lest fifty five(55) patients were referred to SLC(speech, language clinic) respectively. From the patients most of them (24.59%) had motor delay. Then 21.28% had cerebral palsy. After that20.76% had epilepsy/seizure, 14.84% had other neurological disease, 8.89% had speech problem, 6.53% had mental health problem (ASD/ ADHD/ Behavoural problem). 0.85% had ...........