The nutritional impact of a feeding protocol for infants on high flow nasal cannula therapy.

BACKGROUND: Clinicians may be reluctant to feed patients on high-flow nasal cannula (HFNC) therapy, despite studies suggesting it is beneficial and safe. We describe the implementation of a feeding protocol for patients with bronchiolitis on HFNC and determine its effect on nutrition goals. METHODS: Prospective bedside data on enteral volume, feed interruptions, and aspiration events were collected on patients with bronchiolitis who were <24 months of age, treated with HFNC, and fed per a developed protocol. Exclusion criteria included history of prematurity <32 weeks, congenital heart disease, or positive-pressure ventilation before feeding. Length of intensive care unit and hospital stay was compared with both a concurrent cohort (CC) of patients not fed per the protocol and a retrospective cohort (RC) admitted prior to protocol creation. RESULTS: Seventy-eight patients met the criteria for the prospective study arm: 24 patients were included in the CC, and 74 were included in the RC. Seventy-one percent of prospective patients received enteral nutrition (EN) on HFNC day 1 vs 42% of the CC. In the prospective cohort, feed interruption occurred in 23% of patients and was associated with higher flow rates; however, no aspiration events occurred. Patients fed per protocol were fed 8-10 h sooner and discharged 1 day earlier than those in the RC. CONCLUSION: The use of a feeding protocol for patients with bronchiolitis on HFNC was safe and associated with shorter time to initiate EN and shorter length of hospital stay.

Acute Rheumatic Fever in a COVID-19-Positive Pediatric Patient.

Bacterial coinfection and COVID-19 have been reported in pediatric populations. We describe a case of Sydenham's chorea, which is exceedingly rare in developed countries, with concurrent COVID-19. Discussed here is the clinical course of an 8-year-old COVID-positive female with pure Sydenham's chorea and subclinical carditis from acute rheumatic fever. To our knowledge, there are no documented reports of acute rheumatic fever in a pediatric patient with coexisting COVID-19 infection.

Creating a Tool to Assess Interpretive Services Perceptions at a Hospital System Level.

The importance of using professional interpretive services (IS) when communicating with patients and families with limited English proficiency (LEP) is well described in the literature. There is no standardized tool to reliably evaluate IS from the point of view of bedside care providers. Collected local qualitative data and literature review informed an anonymous electronic survey that was distributed to physicians and nursing staff at a tertiary care children's hospital. Authors then used exploratory factor analysis to analyze results. Survey response rate was 27%. Seven key factors were identified; the original survey was revised using the two most impactful questions contributing to each factor. Re-analysis showed Pearson correlation coefficients at or above 0.9. Using this simplified 14 question questionnaire, hospital systems can assess the knowledge, attitudes, self-reported utilization and perceived barriers around IS, allowing for targeted interventions to improve the care of LEP patients.

Suicide Attempt Admissions From a Single Children's Hospital Before and After the Introduction of Netflix Series 13 Reasons Why.

PURPOSE: Release of the Netflix series 13 Reasons Why in March 2017 raised concern over associated suicide attempts. This study aimed to identify trends in self-harm admissions to a tertiary children's hospital with special attention paid to the time after series release. METHODS: Records for admitted patients ages 4-18 years from January 2012 to October 2017 were identified based on ICD codes indicating self-harm. Admissions were grouped by month, and the ARMA (Auto Regression and Moving Average) model was used in analysis. Log transformation was used to obtain a constant variance, and seasonal terms were added for adjustment. A "postintervention" level shift, temporary shift, and linear growth term were incorporated as predictors in ARMA models to test for differences using the series premier as the intervention. Terms from the best fitting model (without intervention effects) were fit to preintervention data and forecast predictions were compared to the observed data from the postintervention period. RESULTS: Seven hundred seventy-five records were included in analysis. There was an increase of .024 in the log of suicide admission counts per month (p < .001). The model that best explained the data was an ARMA (2,2) model with cubic growth curve terms, a post-intervention level shift, and a postintervention linear growth term, indicating an increase in observed over expected admissions following the premiere. CONCLUSIONS: Suicide admission counts increased over the time series. Actual suicide admissions following March 2017 were higher than predicted using the optimal model, suggesting an effect that temporally coincides with the release of 13 Reasons Why.

Improving student documentation using a feedback tool.

BACKGROUND: Medical students are often given non-standardised midpoint feedback and final evaluation on their history and physical examination documentation, despite this written communication being one of the most important aspects of patient care. This study aims to assess the effect of using a standardised feedback tool on overall student documentation performance. METHODS: A standardised written evaluation form, called the history and physical examination write-up assessment (HAPA) form, was previously developed and published in The Clinical Teacher in 2011. This form evaluates the documentation of student communication, data collection and clinical reasoning, and was used to provide midpoint documentation feedback to one group of medical students, whereas a second group received non-standardised midpoint feedback on documentation. Final written history and physical examination documentation from both groups was then evaluated using the standardised tool to assess the effect of receiving more formalised midpoint documentation feedback using the HAPA form. RESULTS: The group receiving standardised midpoint feedback using the HAPA form performed significantly better on the final evaluations of their documentation, especially when examining communication and data collection documentation. Performance in clinical reasoning documentation did not demonstrate a significant change between the two groups. Medical students are often given non-standardised midpoint feedback and final evaluation CONCLUSIONS: The use of a standardised evaluation tool, such as the HAPA form, may be associated with improved student documentation. This form provides educators with an effective tool to use when providing feedback and final evaluation of medical student documentation.

Off-Label Medication use in Children, More Common than We Think: A Systematic Review of the Literature.

CONTENT: Clinician prescribing of off-label medications is common due to a lack of pediatric-specific data regarding the dosing, efficacy and safety of medications regularly prescribed to children. OBJECTIVE: This systematic review summarizes the published incidence of off-label medication use in children from the past 10 years. We also performed a retrospective chart review to determine the incidence of off-label prescriptions for children seen in the OU Physicians clinics. DATA SOURCES: We conducted a literature search of PubMed and OVID Medline from 2007 to 2017. Search terms included off-label use of medications and all child. For the local review, the outpatient electronic medical record (EMR) was queried. STUDY SELECTION: Studies were eligible for inclusion if the study included children < 18 years of age, defined off-label use in the paper, and included the incidence of off-label drug use. DATA EXTRACTION: Each review author extracted the study data from their assigned studies. For the retrospective chart review, the EMR was queried for patients <21 years of age who had a clinic visit and received a new prescription during 2017. RESULTS: We identified 31 studies, with off-label prescription rates from 3.2 % to 95%. The local retrospective chart review included 1,323 prescriptions; 504 were off-label (38.1%) and 819 were approved. The frequency of off-label prescriptions does not differ significantly between the meta-analysis from the systematic review and the local retrospective chart review (30.9% vs 38.1%). CONCLUSIONS: The use of off-label medications in children remains a common practice for pediatric providers.

Transitioning From Medical Educator to Scholarship in Medical Education.

Clinician educators spend most of their time in clinical practice, educating trainees in all types of care settings. Many are involved in formal teaching, curriculum development and learner assessment while holding educational leadership roles as well. Finding time to engage in scholarly work that can be presented and published is an academic expectation, but also a test of efficiency. Just as clinical research originates from problems related to patients, so should educational research originate from issues related to educating the next generation of doctors. Accrediting bodies challenge medical educators to be innovative while faculty already make the best use of the limited time available. One obvious solution is to turn the already existing education work into scholarly work. With forethought, planning, explicit expectations and use of the framework laid out in this article, clinical educators should be able to turn their everyday work and education challenges into scholarly work.

Synergistic interactions of Pseudomonas aeruginosa and Staphylococcus aureus in an in vitro wound model.

In individuals with polymicrobial infections, microbes often display synergistic interactions that can enhance their colonization, virulence, or persistence. One of the most prevalent types of polymicrobial infection occurs in chronic wounds, where Pseudomonas aeruginosa and Staphylococcus aureus are the two most common causes. Although they are the most commonly associated microbial species in wound infections, very little is known about their interspecies relationship. Evidence suggests that P. aeruginosa-S. aureus coinfections are more virulent than monoculture infection with either species; however, difficulties in growing these two pathogens together in vitro have hampered attempts to uncover the mechanisms involved. Here we describe a simple and clinically relevant in vitro wound model that supported concomitant growth of P. aeruginosa and S. aureus. We observed that the ability of P. aeruginosa and S. aureus to survive antibiotic treatment increased when they were grown together in planktonic cocultures and that antibiotic tolerance was further enhanced when they were grown together in the wound model. We attributed this enhanced tolerance to both the "host-derived" and "bacterium-derived" matrix components. Taken together, our data indicate that P. aeruginosa and S. aureus may benefit each other by coinfecting wounds and that the host-derived matrix may serve as important a role as the bacterium-derived matrix in protecting bacteria from some antibiotics.