Effect of Viral Illness on Procalcitonin as a Predictor of Bacterial Infection in Febrile Infants.

OBJECTIVE: The impact of confirmed viral infections (CVI) on procalcitonin (PCT) levels in febrile infants aged 8-60 days with a bacterial illness (BI) is unknown. The objectives of the study were to (1) examine the association of CVI with PCT levels in patients with/without a concurrent BI, defined as bacteremia, meningitis, or urinary tract infection, and (2) assess PCT as a predictor of BI in infants with a concurrent CVI. METHODS: In this single-center, retrospective cohort study, we examined febrile infants aged 8-60 days presenting between January 1, 2018 and December 31, 2020. PCT levels were compared between groups, according to results of bacterial cultures and viral tests, using the Wilcoxon rank test. The prediction ability of PCT to detect BI with/without concurrent CVI was assessed by using area under the curve from logistic regression. RESULTS: Patients included: 404 BI-/CVI+, 73 BI+/CVI-, 48 BI+/CVI+, and 138 BI-/CVI-. Median PCT level in the BI+/CVI+ group was significantly lower when compared to BI+/CVI- (0.36 ng/mL vs 0.89 ng/mL), but significantly higher than the BI-/CVI- group (0.36 ng/mL vs 0.1 ng/mL). The presence of a CVI reduced the sensitivity of PCT in BI detection (68% vs 44%), with minimal impact specificity (93% vs 96%). CONCLUSIONS: In previously healthy febrile infants 8-60 days old, the presence of a CVI reduces the sensitivity of PCT BI detection without impacting its specificity. The impact of a CVI on PCT levels in febrile infants has implications for how this marker of infection should be considered when assessing risk of BI in infants.

Decreasing Goal Oxygen Saturations in Bronchiolitis Is Associated With Decreased Length of Stay.

OBJECTIVES: For patients hospitalized with bronchiolitis, many hospitals have implemented clinical practice guidelines to decrease variability in care. Our hospital updated its bronchiolitis clinical pathway by lowering goal oxygen saturation from 90% to 88%. We compared clinical outcomes before and after this change within the context of the pathway update. METHODS: This was a retrospective analysis of patients <24 months old admitted to a pediatric tertiary care center from 2019 to 2021 with bronchiolitis. Patients with congenital heart disease, asthma, home oxygen, or admitted to an ICU were excluded. The data were stratified for patients admitted before and after the clinical pathway update. Statistical methods consisted of 2 group comparisons using the χ-square test for categorical variables, the Wilcoxon rank-sum test for continuous variables, and multiple regression analysis. RESULTS: A total of 1386 patients were included, 779 preupdate and 607 postupdate. There was no statistically significant difference in the admission rate of patients presenting to the emergency department with bronchiolitis between the 2 groups (P value .60). The median time to room air was 40.0 hours preupdate versus 30.0 hours postupdate (P value < .001). The median length of stay was 48.0 hours preupdate versus 41.0 hours postupdate (P value < .001). Readmission rate was 2.7% within 7 days of discharge preupdate, and 2.1% postupdate (P value .51). CONCLUSIONS: Decreasing goal oxygen saturation to 88% was associated with a statistically significant decrease in time spent on oxygen and length of stay for patients admitted with bronchiolitis with no increase in readmissions.

Calling Consults: A Workshop to Teach Trainees Using Both Didactic and Small Group-based Learning.

Background: Safe patient care includes effective communication. The Accreditation Council for Graduate Medical Education common program requirements include core requirements for trainees to act in a consultative manner and communicate effectively. However, trainees do not commonly receive formal education on this topic. Objective: We created a 1-hour workshop to teach residents and fellows how to effectively call consults, including how to formulate a cogent and comprehensive consult question. Methods: The workshop, delivered over a 1-hour noon conference, included a didactic portion and interactive small-group case-based learning. We used pre- and postworkshop surveys to assess learners' prior training, knowledge, and comfort levels in calling consults. Subspecialists answered a separate survey about the quality of consults received from trainees before and 30 days after the workshop. Results: Seventy-three trainees attended the workshop (41.2% of total trainees invited). After the workshop, the percentage of learners who identified as very or somewhat comfortable with calling consults increased from 82% to 91%. Before the workshop, 87% of trainees could identify key elements in a consult, which increased to 100% after the workshop. There was not a statistically significant improvement in subspecialists' ratings of the overall quality of consults they received 30 days after the workshop. Conclusion: Training learners on the key components and etiquette of calling consults is crucial for the development of effective communication among providers. This training is generally lacking from undergraduate medical education; thus, it is important to provide education in calling consults during residency and fellowship.

Screening for Social Determinants of Health in Hospitalized Children.

OBJECTIVES: Outpatient screening for social determinants of health (SDH) improves patient access to resources. However, no studies have examined if and how inpatient pediatric providers perform SDH screening. We aimed to identify inpatient pediatric provider screening practices for SDH, barriers to screening, and the acceptability of screening for hospitalized patients. METHODS: We conducted a multicenter descriptive study at 4 children's hospitals surveying inpatient hospitalists and nurses on the general wards about their SDH screening practices. A survey instrument was developed on the basis of literature pertaining to SDH, content expert review, cognitive interviews, and survey piloting. Descriptive statistics and logistic regression analyses are reported. RESULTS: Results from 146 hospitalists and 227 nurses were analyzed (58% and 26% response rate, respectively). Twenty-nine percent of hospitalists and 41% of nurses reported screening for ≥1 SDH frequently or with every hospitalized patient. Only 26% of hospitalists reported consistently communicating SDH needs with primary care providers. Most respondents (97% of hospitalists and 65% of nurses) reported they do not use a specific screening tool, and only 34% of hospitalists and 32% of nurses reported feeling competent screening for SDH. Lack of time, resources, and a standardized inpatient screening tool were reported as barriers to screening. CONCLUSIONS: Hospitalization provides an opportunity for SDH screening and connecting patients to resources; however, a minority of pediatric providers currently report screening. Professional development activities training inpatient providers in SDH screening, using a screening instrument, and communicating identified needs to primary care providers may improve the effectiveness of SDH screening in the hospital.

Hospital-Level Variation in Practice Patterns and Patient Outcomes for Pediatric Patients Hospitalized With Functional Constipation.

BACKGROUND AND OBJECTIVE: Constipation is a common pediatric condition with a prevalence of 3% to 5% in children aged 4 to 17 years. Currently, there are no evidence-based guidelines for the management of pediatric patients hospitalized with constipation. The primary objective was to evaluate practice patterns and patient outcomes for the hospital management of functional constipation in US children's hospitals. METHODS: We conducted a multicenter, retrospective cohort study of children aged 0 to 18 years hospitalized for functional constipation from 2012 to 2014 by using the Pediatric Health Information System. Patients were included by using constipation and other related diagnoses as classified by International Classification of Diseases, Ninth Revision. Patients with complex chronic conditions were excluded. Outcome measures included percentage of hospitalizations due to functional constipation, therapies used, length of stay, and 90-day readmission rates. Statistical analysis included means with 95% confidence intervals for individual hospital outcomes. RESULTS: A total of 14 243 hospitalizations were included, representing 12 804 unique patients. The overall percentage of hospitalizations due to functional constipation was 0.65% (range: 0.19%-1.41%, P < .0001). The percentage of patients receiving the following treatment during their hospitalization included: electrolyte laxatives: 40% to 96%; sodium phosphate enema: 0% to 64%; mineral oil enema: 0% to 61%; glycerin suppository: 0% to 37%; bisacodyl 0% to 47%; senna: 0% to 23%; and docusate 0% to 11%. Mean length of stay was 1.97 days (range: 1.31-2.73 days, P < .0001). Mean 90-day readmission rate was 3.78% (range: 0.95%-7.53%, P < .0001). CONCLUSIONS: There is significant variation in practice patterns and clinical outcomes for pediatric patients hospitalized with functional constipation across US children's hospitals. Collaborative initiatives to adopt evidence-based best practices guidelines could help standardize the hospital management of pediatric functional constipation.

Perceived core competency achievements of fellowship and non-fellowship-trained early career pediatric hospitalists.

BACKGROUND: The pediatric hospital medicine (PHM) core competencies were established in 2010 to identify the specific knowledge base and skill set needed to provide the highest quality of care for hospitalized children. The objectives of this study were to examine the perceived core competency achievements of fellowship-trained and non-fellowship-trained early career pediatric hospitalists and identify perceived gaps in our current training models. METHODS: An anonymous Web-based survey was distributed in November 2013. Hospitalists within 5 years of their residency graduation reported their perceived competency in select PHM core competencies. χ(2) and multiprobit regression analyses were utilized. RESULTS: One hundred ninety-seven hospitalists completed the survey and were included; 147 were non-fellowship-trained and 50 were PHM fellowship graduates or current PHM fellows. Both groups reported feeling less than competent in sedation and aspects of business practice. Non-fellowship-trained hospitalists also reported mean scores in the less than competent range in intravenous access/phlebotomy, technology-dependent emergencies, performing Plan-Do-Study-Act process and root cause analysis, defining basic statistical terms, and identifying research resources. Non-fellowship-trained hospitalists reported mean competency scores greater than fellowship-trained hospitalists in pain management, newborn care, and transitions in care. CONCLUSIONS: Early career pediatric hospitalists report deficits in several of the PHM core competencies, which should be considered when designing PHM-specific training in the future. Fellowship-trained hospitalists report higher levels of perceived competency in many core areas.

Appropriateness of testing for serious bacterial infection in children hospitalized with bronchiolitis.

OBJECTIVE: The goal of this study was to evaluate provider practice patterns for evaluation of serious bacterial infection (SBI) in patients hospitalized with bronchiolitis and to assess the association of SBI testing with length of stay and antibiotic use. DESIGN: This was a retrospective chart review of hospitalized patients <24 months of age with a discharge diagnosis of bronchiolitis from 2 separate study sites during 2004 to 2008. Patient characteristics, laboratory testing, antibiotic use, and clinical outcomes were assessed in relation to SBI testing. RESULTS: A total of 1233 charts met inclusion criteria. The incidence of urinary tract infections in patients who underwent urine testing was 2.3%. Of the 367 patients undergoing blood culture testing, all 13 positive-result blood cultures were contaminated specimens. There were no cases of meningitis. In total, 64.5% of patients tested for SBI had a blood culture obtained, 45.0% had an urinalysis or urine culture, and 16.3% had a cerebral spinal fluid culture obtained. Of those patients who underwent SBI testing, 53.8% received antibiotics versus 19.1% who did not (P < .0001). Length of stay for patients undergoing SBI testing was 3.4 days versus 2.3 days for those without SBI testing (P < .0001). There was no significant difference in readmission rates. CONCLUSIONS: SBI is uncommon in children hospitalized for bronchiolitis, and urinary tract infection is the most common diagnosis. In the evaluation of SBI in bronchiolitis, providers more frequently obtain blood cultures than urinalysis and/or urine cultures. Evaluation for SBI is associated with increased antibiotic use and increased LOS.

Hospitalist and nonhospitalist adherence to evidence-based quality metrics for bronchiolitis.

OBJECTIVES: Hospitalists are a new subgroup of pediatricians. However, data comparing quality of care between hospitalists and nonhospitalists are limited. Bronchiolitis, a common cause of pediatric hospital admission, is an appropriate condition for evaluating inpatient quality of care. The goal of this study was to identify quality indicators for the evaluation and treatment of children hospitalized with bronchiolitis based on the 2006 American Academy of Pediatrics guidelines and to assess differences in adherence rates to these indicators between hospitalist and nonhospitalist pediatricians. METHODS: This was a retrospective chart review of children admitted to 2 academic centers in 2007 and 2008. Reviewers selected charts with a discharge diagnosis of bronchiolitis and collected data on evaluation, treatment, length of stay, readmission, and adverse outcomes. RESULTS: Reviewers analyzed 713 charts. In children without objective response to bronchodilator therapy, hospitalists and nonhospitalists discontinued albuterol and racemic epinephrine similarly. Hospitalists discontinued unnecessary systemic corticosteroid therapy (75.0% vs 42.4%; P= .001) and antibiotic therapy (71.0% vs 48.6%; P= .007) more frequently than nonhospitalists. CONCLUSIONS: These data suggest hospitalists better adhere to selected portions of the American Academy of Pediatrics bronchiolitis guidelines, thus providing higher quality of care. Quality indicators used in this study can distinguish physician performance in the inpatient management of bronchiolitis.

Effects of a supervised home-based aerobic and progressive resistance training regimen in women infected with human immunodeficiency virus: a randomized trial.

BACKGROUND: Women infected with human immunodeficiency virus (HIV) increasingly demonstrate abnormalities in fat distribution and metabolism; however, the effects of a home-based exercise regimen in this group have not been investigated. METHODS: We conducted a 16-week randomized intervention study of a supervised home-based progressive resistance training and aerobic exercise program in 40 HIV-infected women with increased waist-hip ratio and self-reported fat redistribution. Cross-sectional muscle area and muscle attenuation were measured by computed tomography. Cardiorespiratory fitness was determined by calculated maximum oxygen consumption (VO2max) and strength by 1-repetition maximum. RESULTS: Cardiorespiratory fitness (VO2max) was markedly lower at baseline (median [95% confidence interval], 15.4 [8.3-25.2] mL x kg(-1) x min(-1)) than reported values for healthy female subjects (26-35 mL x kg(-1) x min(-1)). Subjects randomized to exercise had significant improvement in mean +/- SEM VO2max (1.5 +/- 0.8 vs -2.5 +/- 1.6 mL x kg(-1) x min(-1); P<.001) and endurance (1.0 +/- 0.3 vs -0.6 +/- 0.3 minute; P<.001). Strength increased at the knee extensors, pectoralis, knee flexors, shoulder abductors, ankle plantar flexors, and elbow flexors (all P<.001). Total muscle area (6 +/- 1 vs 2 +/- 1 cm2; P = .02) and attenuation (2 +/- 1 vs -1 +/- 1 Hounsfield unit; P = .03) increased in the exercise group. No significant difference was seen in lipid levels, blood pressure, or abdominal visceral fat between the groups, but subjects randomized to exercise reported improved energy and appearance. CONCLUSIONS: A 16-week, supervised, home-based exercise regimen improved measures of physical fitness in HIV-infected women. The effects on strength were most significant, but improvements in cardiorespiratory fitness, endurance, and body composition were also seen.

Increased intramyocellular lipid accumulation in HIV-infected women with fat redistribution.

The human immunodeficiency virus (HIV)-lipodystrophy syndrome is associated with fat redistribution and metabolic abnormalities, including insulin resistance. Increased intramyocellular lipid (IMCL) concentrations are thought to contribute to insulin resistance, being linked to metabolic and body composition variables. We examined 46 women: HIV infected with fat redistribution (n = 25), and age- and body mass index-matched HIV-negative controls (n = 21). IMCL was measured by 1H-magnetic resonance spectroscopy, and body composition was assessed with computed tomography, dual-energy X-ray absorptiometry (DEXA), and magnetic resonance imaging. Plasma lipid profile and markers of glucose homeostasis were obtained. IMCL was significantly increased in tibialis anterior [135.0 +/- 11.5 vs. 85.1 +/- 13.2 institutional units (IU); P = 0.007] and soleus [643.7 +/- 61.0 vs. 443.6 +/- 47.2 IU, P = 0.017] of HIV-infected subjects compared with controls. Among HIV-infected subjects, calf subcutaneous fat area (17.8 +/- 2.3 vs. 35.0 +/- 2.5 cm2, P < 0.0001) and extremity fat by DEXA (11.8 +/- 1.1 vs. 15.6 +/- 1.2 kg, P = 0.024) were reduced, whereas visceral abdominal fat (125.2 +/- 11.3 vs. 74.4 +/- 12.3 cm2, P = 0.004), triglycerides (131.1 +/- 11.0 vs. 66.3 +/- 12.3 mg/dl, P = 0.0003), and fasting insulin (10.8 +/- 0.9 vs. 7.0 +/- 0.9 microIU/ml, P = 0.004) were increased compared with control subjects. Triglycerides (r = 0.39, P = 0.05) and extremity fat as percentage of whole body fat by DEXA (r = -0.51, P = 0.01) correlated significantly with IMCL in the HIV but not the control group. Extremity fat (beta = -633.53, P = 0.03) remained significantly associated with IMCL among HIV-infected patients, controlling for visceral abdominal fat, abdominal subcutaneous fat, and antiretroviral medications in a regression model. These data demonstrate increased IMCL in HIV-infected women with a mixed lipodystrophy pattern, being most significantly associated with reduced extremity fat. Further studies are necessary to determine the relationship between extremity fat loss and increased IMCL in HIV-infected women.