Improving Follow-Up of Tests Pending at Discharge.

BACKGROUND AND OBJECTIVES: Follow-up on results of inpatient tests pending at discharge (TPAD) must occur to ensure patient safety and high-quality care continue after discharge. We identified a need to improve follow-up of TPAD and began a quality improvement initiative with an aim of reducing the rate of missed follow-up of TPAD to ≤20% within 12 months. METHODS: The team used the Plan-Do-Study-Act method of quality improvement and implemented a process using reminder messages in the electronic health record. We collected data via retrospective chart review for the 6 months before the intervention and monthly thereafter. The primary outcome measure was the percentage of patients with missed follow-up of TPAD, defined as no documented follow-up within 72 hours of a result being available. The use of a reminder message was monitored as a process measure. RESULTS: We reviewed charts of 764 discharged patients, and 216 (28%) were noted to have TPAD. At baseline, the average percentage of patients with missed follow-up was 80%. The use of reminder messages was quickly adopted. The average percentage of patients with missed follow-up of TPAD after beginning the quality improvement interventions was 35%. CONCLUSIONS: We had significant improvement in follow-up after our interventions. Additional work is needed to ensure continued and sustained improvement, focused on reducing variability in performance between providers and investing in technology to allow for automation of the follow-up process.

Does Non-Neurologic Multiorgan Dysfunction After Out-of-Hospital Cardiac Arrest among Children Admitted in Coma Predict Outcome 1 Year Later?

In this article, we investigated whether non-neurologic multiorgan dysfunction syndrome (MODS) following out-of-hospital cardiac arrest (OHCA) predicts poor 12-month survival. We conducted a secondary data analysis of therapeutic hypothermia after pediatric cardiac arrest out-of-hospital randomized trial involving children who remained unconscious and intubated after OHCA ( n = 237). Associations between MODS and 12-month outcomes were assessed using multivariable logistic regression. Non-neurologic MODS was present in 95% of patients and sensitive (97%; 95% confidence interval [CI]: 93-99%) for 12-month survival but had poor specificity (10%; 95% CI: 4-21%). Development of non-neurologic MODS is not helpful to predict long-term neurologic outcome or survival after OHCA.

Pediatricians' Knowledge, Attitudes, and Behaviors to Screening Children After Complicated Mild TBI: A Survey.

OBJECTIVE: To understand pediatricians' attitudes, knowledge, and behaviors about the care of children with complicated mild traumatic brain injury (TBI). PARTICIPANTS: A total of 3500 pediatricians randomly selected from the American Medical Association Master File. DESIGN: It was a cross-sectional survey. MAIN MEASURES: A survey developed to assess pediatricians' attitudes toward following children with complicated mild TBI for cognitive and behavioral sequelae; their knowledge of TBI sequelae; and their usual evaluation and management of children after TBI. RESULTS: There were 576 (16.5%) completed responses. Most pediatricians (51%) see 1 or 2 patients with complicated mild TBI annually. Most do not think that pediatricians are the correct clinician group to be primarily responsible for following children with complicated mild TBI for cognitive (74%) or behavioral sequelae (54%). Pediatricians report difficulty referring children for cognitive (56%) and behavioral (48%) specialty services. Pediatricians have good knowledge of short-term complications of complicated mild TBI. CONCLUSION: Pediatricians do not think they are the clinicians that should primarily care for children after hospitalization for complicated mild TBI; however, other clinicians are frequently not accessible. Pediatricians need educational and referral support to provide surveillance for injury sequelae in this group of children.

Development and Prospective Validation of Tools to Accurately Identify Neurosurgical and Critical Care Events in Children With Traumatic Brain Injury.

OBJECTIVE: To develop and validate case definitions (computable phenotypes) to accurately identify neurosurgical and critical care events in children with traumatic brain injury. DESIGN: Prospective observational cohort study, May 2013 to September 2015. SETTING: Two large U.S. children's hospitals with level 1 Pediatric Trauma Centers. PATIENTS: One hundred seventy-four children less than 18 years old admitted to an ICU after traumatic brain injury. MEASUREMENTS AND MAIN RESULTS: Prospective data were linked to database codes for each patient. The outcomes were prospectively identified acute traumatic brain injury, intracranial pressure monitor placement, craniotomy or craniectomy, vascular catheter placement, invasive mechanical ventilation, and new gastrostomy tube or tracheostomy placement. Candidate predictors were database codes present in administrative, billing, or trauma registry data. For each clinical event, we developed and validated penalized regression and Boolean classifiers (models to identify clinical events that take database codes as predictors). We externally validated the best model for each clinical event. The primary model performance measure was accuracy, the percent of test patients correctly classified. The cohort included 174 children who required ICU admission after traumatic brain injury. Simple Boolean classifiers were greater than or equal to 94% accurate for seven of nine clinical diagnoses and events. For central venous catheter placement, no classifier achieved 90% accuracy. Classifier accuracy was dependent on available data fields. Five of nine classifiers were acceptably accurate using only administrative data but three required trauma registry fields and two required billing data. CONCLUSIONS: In children with traumatic brain injury, computable phenotypes based on simple Boolean classifiers were highly accurate for most neurosurgical and critical care diagnoses and events. The computable phenotypes we developed and validated can be used in any observational study of children with traumatic brain injury and can reasonably be applied in studies of these interventions in other patient populations.

The association between cognitive impairment and functional outcome in hospitalised older patients: a systematic review and meta-analysis.

Background: in hospitalised older adults, cognitive impairments are common and may be associated with functional outcomes. Our aim was to systematically review this association. Method: we systematically searched MEDLINE, CINAHL, AMED and PsycINFO from inception to April 2016. Non-English language studies were filtered out at search stage. All types of studies were considered for inclusion except reviews, conference abstracts, dissertations and case studies. Population: community-dwelling or institutionalised older adults aged 65 years or more, who are acutely hospitalised and have information on history of dementia and/or cognitive scores on admission. Setting: acute hospital (excluding critical care and subacute or intermediate care). Outcome of interest: change in a measure of physical function or disability between pre-admission or admission, and discharge or post-discharge. This review was registered on PROSPERO (CRD42016035978). Results: the search returned 5,988 unique articles, of which 34 met inclusion criteria. All studies were observational, with 30 prospective and 4 retrospective from 14 countries, recruiting from general medicine (n = 11), geriatric medicine (n = 11) and mixed (n = 12) wards. Twenty-six studies (54,637 participants) were suitable for the quantitative synthesis. The meta-analysis suggested that cognitive impairment was associated with functional decline in hospitalised older adults (risk ratio (RR): 1.64; 95% confidence interval (CI): 1.45-1.86; P < 0.01). Results were similar in subanalyses focusing on diagnosis of dementia (RR: 1.36; 95% CI: 1.05-1.76; P = 0.02; n= 2,248) or delirium (RR: 1.55; 95% CI: 1.31-1.83; P < 0.01; n= 1,677). Conclusion: cognitive impairments seem associated with functional decline in hospitalised older people. Causality cannot be inferred, and limitations include low quality of studies and possible confounding.

Functional Status Scale in Children With Traumatic Brain Injury: A Prospective Cohort Study.

OBJECTIVES: In children with traumatic brain injury, 1) to describe the hospital discharge functional outcome and change from baseline function using the Functional Status Scale and 2) to determine any associations between discharge Functional Status Scale and age, injury mechanism, neurologic examination, imaging, and other predictors of outcome. DESIGN: Prospective observational cohort study, May 2013 to November 2015. SETTING: Two U.S. children's hospitals designated as American College of Surgeons level 1 pediatric trauma centers. PATIENTS: Children less than 18 years old admitted to an ICU with acute traumatic brain injury and either a surgical or critical care intervention within the first 24 hours or in-hospital mortality. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital discharge Functional Status Scale. Most, 133 of 196 (68%), had severe traumatic brain injury (admission Glasgow Coma Scale, 3-8). Overall hospital mortality was 14%; 20% among those with severe traumatic brain injury. Hospital discharge Functional Status Scale had an inverse relationship with Glasgow Coma Scale: for each increase in admission Glasgow Coma Scale by 1, the discharge Functional Status Scale decreased by 0.5 (95% CI, 0.7-0.3). Baseline Functional Status Scale was collected at one site (n = 75). At that site, nearly all (61/62) of the survivors had normal or near-normal (≤ 7) preinjury Functional Status Scale. More than one-third, 23 of 62 (37%), of survivors had new morbidity at hospital discharge (increase in Functional Status Scale, ≥ 3). Among children with severe traumatic brain injury who had baseline Functional Status Scale collected, 21 of 41 survivors (51%) had new morbidity at hospital discharge. The mean change in Functional Status Scale from baseline to hospital discharge was 3.9 ± 4.9 overall and 5.2 ± 5.4 in children with severe traumatic brain injury. CONCLUSIONS: More than one-third of survivors, and approximately half of survivors with severe traumatic brain injury, will have new morbidity. Hospital discharge Functional Status Scale, change from baseline Functional Status Scale, and new morbidity acquisition can be used as outcome measures for hospital-based care process improvement initiatives and interventional studies of children with traumatic brain injury.

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury.

OBJECTIVE: To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. DESIGN: Prospective, observational cohort study. SETTING: Twelve PICUs in North Carolina. PATIENTS: All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. CONCLUSION: Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.

Spontaneous haemoperitoneum due to a sigmoid diverticulum.

Spontaneous haemoperitoneum is rare. When it occurs it is a life-threatening condition. Common causes of this are gynaecological in nature and rarely due to colonic diverticular perforation. Diverticulitis is a common condition affecting people in western countries. This presentation of spontaneous haemoperitoneum highlights the disproportionate abdominal pain and opioid-induced constipation. Significant bloods on admission included haemoglobin of 148 g/L, C reactive protein (CRP) of 1.1 mg/L, white cell count (WCC) of 12.7×10(9)/L (neutrophils 10.9×10(9)/L). Bloods repeated 10 h later revealed the haemoglobin had dropped to 100 g/L, CRP had increased significantly to 120 mg/L, WCC: 7.4×10(9)/L (neutrophils 5.3×10(9)/L) and a reduced packed cell volume: 0.307 L/L. CT scan revealed free fluid and a possible mass. At laparoscopy, frank haemoperitoneum was seen and a decision was made to open and perform a Hartmann's procedure. The patient did very well postoperatively and was discharged on the ninth postoperative day. He is currently awaiting reversal of the ileostomy.

Improvement in adolescent screening and counseling rates for risk behaviors and developmental tasks.

BACKGROUND: High-quality preventive services for youth aged 11 to 18 include assessment and counseling regarding health behavior risks and developmental tasks/strengths of adolescence. Nationally, primary care health behavior risk screening and counseling rates lag considerably behind other preventive health services. The purpose of this project was to assist pediatric and family medicine practices to make office systems-based changes that promote comprehensive screening and counseling for risks and developmental tasks/strengths during adolescent preventive services visits. METHODS: Over a 9-month period, 7 pediatric and 1 family medicine primary care practices (13 physicians and 3 nurse practitioners) participated in a modified Breakthrough Series Collaborative. This project was designed to support primary care practitioner efforts to implement comprehensive screening and counseling for risk behaviors and developmental tasks/strengths for their adolescent patients and increase the rate of brief office intervention and referral. Composite variables were designed to reflect whether screening and counseling were documented for risks and developmental tasks. Statistical comparisons were made by using the nonparametric Wilcoxon matched-pairs signed rank test. RESULTS: There were increases in the composite measures of screening and counseling for risk behaviors (all 6 risks: 26%-50%, P = .01) and 3 of 4 developmental tasks/strengths (32%-66%, P = .01). Documentation of office interventions for identified risks and out-of office referral rates did not change. CONCLUSIONS: With the use of an office systems-based approach, screening and counseling for all critical risk behaviors and developmental tasks/strengths during adolescent preventive services visits can be improved in primary care practices.

The wrap-up: a unique forum to support pediatric residents when faced with the death of a child.

OBJECTIVE: The project intended to describe the format of the Wrap-up, a unique multidisciplinary guided debriefing following a child's death. Specific feedback from pediatric residents was sought to assess the model. METHODS: The Wrap-ups were timely (within 48 hours of a death), consistent (conducted after each pediatric intensive care unit (PICU) death), multidisciplinary (all care providers were invited), and specifically conducted by someone trained in postdeath facilitation. The role of the conductor was focused on being inclusive, navigating the discussion, diffusing areas of conflict or angst, and managing the tone of the meeting. Resident feedback was obtained by a one-time (May 2010) anonymous internet-based survey, with both open-ended free-text questions and five-point Likert scale queries. Surveyed were all residents rotating though the PICU between 2007 and 2010. Open-ended free-text responses were analyzed using content analysis methods by combining recurrent themes and organizing by main components of the Wrap-up. Quantitative responses, via a five-point Likert scale, were averaged. RESULTS: Between 2007 and 2010, there were 36 PICU deaths. The average age was nine years old. All deaths had an accompanying conductor-led Wrap-up occurring, on average, two days after the death. Sixty percent (27/45) of pediatric residents completed the survey. Their qualitative responses showed that the key components (timely, multidisciplinary, and specifically conducted) of the Wrap-ups were valuable. Quantitatively, they agreed or strongly agreed that the consistent Wrap-ups improved end-of-life care, teamwork, stress surrounding the death, and the ability to care for others. CONCLUSION: The Wrap-up, a unique forum for debriefing after a pediatric death, was well-received by residents and assisted them with processing, understanding, and resolving their experience regarding the pediatric death. The Wrap-up was a valuable addition to residents' experience and education in pediatric critical care medicine and can be replicated in other institutions.

Is surgical intervention frequently required for medically managed macroprolactinomas? A study of spontaneous cerebrospinal fluid rhinorrhea.

BACKGROUND: The frequency of spontaneous CSF rhinorrhea in macroprolactinoma patients is poorly documented and was previously thought to be a very rare occurrence. METHODS: Thirty patients with macroprolactinomas (>1.0 cm diameter) identified from the Swansea neuroendocrine database were studied retrospectively. RESULTS: At presentation, the median serum prolactin was 28,354 (range, 1844 to >6,000,000) mU/L; radiologically, 4 adenomas were invading the cavernous sinus, one the sphenoid sinus and 5 both the cavernous and sphenoid sinus. After commencement of medical therapy, 4 subjects developed CSF rhinorrhea requiring surgical correction; all 4 had tumors invading both the cavernous and sphenoid sinus and an initial serum prolactin more than 75,000 mU/L. One subject developed an acute psychosis, and a man who presented with delayed puberty committed a serious sexual offense. CONCLUSIONS: Serious adverse effects are not uncommon in medically treated macroprolactinoma patients. Subjects with adenomas invading the sphenoid sinus have a high risk of developing CSF rhinorrhea that requires neurosurgical intervention.

PICK1-mediated glutamate receptor subunit 2 (GluR2) trafficking contributes to cell death in oxygen/glucose-deprived hippocampal neurons.

Oxygen and glucose deprivation (OGD) induces delayed cell death in hippocampal CA1 neurons via Ca(2+)/Zn(2+)-permeable, GluR2-lacking AMPA receptors (AMPARs). Following OGD, synaptic AMPAR currents in hippocampal neurons show marked inward rectification and increased sensitivity to channel blockers selective for GluR2-lacking AMPARs. This occurs via two mechanisms: a delayed down-regulation of GluR2 mRNA expression and a rapid internalization of GluR2-containing AMPARs during the OGD insult, which are replaced by GluR2-lacking receptors. The mechanisms that underlie this rapid change in subunit composition are unknown. Here, we demonstrate that this trafficking event shares features in common with events that mediate long term depression and long term potentiation and is initiated by the activation of N-methyl-d-aspartic acid receptors. Using biochemical and electrophysiological approaches, we show that peptides that interfere with PICK1 PDZ domain interactions block the OGD-induced switch in subunit composition, implicating PICK1 in restricting GluR2 from synapses during OGD. Furthermore, we show that GluR2-lacking AMPARs that arise at synapses during OGD as a result of PICK1 PDZ interactions are involved in OGD-induced delayed cell death. This work demonstrates that PICK1 plays a crucial role in the response to OGD that results in altered synaptic transmission and neuronal death and has implications for our understanding of the molecular mechanisms that underlie cell death during stroke.

Practice Nurses' views of their role in the management of Chronic Fatigue Syndrome/Myalagic Encephalitis: a qualitative study.

BACKGROUND: NICE guidelines suggest that patients with Chronic Fatigue Syndrome/Myalgic Encephalitis (CFS/ME) should be managed in Primary Care. Practice Nurses are increasingly being involved in the management of long-term conditions, so are likely to also have a growing role in managing CFS/ME. However their attitudes to, and experiences of patients with CFS/ME and its management must be explored to understand what barriers may exist in developing their role for this group of patients. The aim of this study was to explore Practice Nurses' understanding and beliefs about CFS/ME and its management. METHODS: Semi-structured interviews with 29 Practice Nurses. Interviews were transcribed verbatim and an iterative approach used to develop themes from the dataset. RESULTS: Practice nurses had limited understanding about CFS/ME which had been largely gained through contact with patients, friends, personal experiences and the media rather than formal training. They had difficulty seeing CFS/ME as a long term condition. They did identify a potential role they could have in management of CFS/ME but devalued their own skills in psychological intervention, and suggested counselling would be an appropriate therapeutic option. They recognised a need for further training and on going supervision from both medical and psychological colleagues. Some viewed the condition as contentious and held pejorative views about CFS/ME. Such scepticism and negative attitudes will be a significant barrier to the management of patients with CFS/ME in primary care. CONCLUSION: The current role of Practice Nurses in the ongoing management of patients with CFS/ME is limited. Practice Nurses have little understanding of the evidence-base for treatment of CFS/ME, particularly psychological therapies, describing management options in terms of advice giving, self-help or counselling. Practice Nurses largely welcomed the potential development of their role in this area, but identified barriers and training needs which must be addressed to enable them to feel confident managing of patients with this condition. Training must begin by addressing negative attitudes to patients with CFS/ME.

Inspiring healthy adolescent choices: a rationale for and guide to strength promotion in primary care.

The social, emotional, and biological health of adolescents requires their development as autonomous beings who make responsible decisions about their own health. Clinicians can assist in this development by adopting a strength-based approach to adolescent health care, which applies concepts from positive youth development to the medical office setting.

The parenting project for teen mothers: the impact of a nurturing curriculum on adolescent parenting skills and life hassles.

OBJECTIVE: Many teen parents and their babies are at a significant disadvantage because of poverty and inadequate parenting skills. We undertook a study aimed at increasing parenting skills and improving attitudes of teen mothers through a structured psychoeducational group model based on the Nurturing Curriculum. METHODS: All adolescent mothers in the Young Parents' Program were offered enrollment in a 12-week group parenting curriculum (intervention group) and were compared with those who declined the intervention but agreed to participate as comparison subjects (comparison group). This study had an intervention-comparison group design with pretest and posttest measures, including the Adult-Adolescent Parenting Inventory (AAPI), the Maternal Self-Report Inventory (MSRI), and the Parenting Daily Hassles Scale (Hassles Scale). RESULTS: There were 91 young mothers in the intervention group compared with 54 in the comparison group. While controlling for mother's age, baby's age, and race, the repeated-measures analyses showed that mothers who participated in the intervention group or attended more group sessions experienced improvements in their mothering role (MSRI) (trend), perception of childbearing experience (MSRI), appropriate developmental expectations of their child (AAPI), empathy for the baby (AAPI), and a reduction in the frequency of hassles in child and family events (Hassles Scale). CONCLUSION: The intervention group showed improvement in parenting skills and life hassles after participation in the intervention curriculum. More interventions are needed to confirm the positive effect of the group-based interventions on parenting and life skills of young mothers that may improve the social, emotional, and cognitive outcomes for the children born to teen parents.

Childhood and adolescent sexuality.

Sexuality is an important aspect of the lives of all human beings, including children and adolescents. The clinician can provide important guidance to pediatric patients and their parents regarding the healthy development of sexuality. Counseling techniques are important, including the "helping skill" model, in which the clinician can state the problem, identify options for the patient, identify consequences of each option, help the patient make a plan, and develop a plan for check back and follow-up.