Improving Prescribing for Otitis Media in a Pediatric Emergency Unit: A Quality Improvement Initiative.

Acute otitis media (AOM) is a commonly overtreated pediatric diagnosis. The American Academy of Pediatrics (AAP) recommends shorter antibiotic courses and wait-and-see prescriptions (WSPs) for healthy children with mild-to-moderate AOM. Still, clinicians do not consistently prescribe these in pediatric emergency units (EUs). Methods: We performed a quality improvement project to improve antibiotic prescribing in a tertiary pediatric EU over 16 months, focusing on shorter prescription durations and WSPs. We assessed AOM management via chart review, then implemented interventions, including clinician education, a guideline card, visual reminders, and updated emails. In addition, we contacted a percentage of families after their visit to assess their child's outcome and parental satisfaction. Results: Our baseline data showed that only 39% of patients prescribed antibiotics were prescribed an appropriate duration based on age and estimated AOM severity, and only 3% were prescribed WSPs. Via 2 plan-do-study-act (PDSA) cycles, we increased the percentage of patients who received appropriate antibiotics to an average of 67%, sustained for >6 months. Follow-up phone calls suggested no difference in satisfaction or need for nonroutine follow-up care based on prescription length. We did not see a substantial increase in WSPs. Conclusions: AOM management in our children's hospital's EU was often inconsistent with AAP guidelines. Two PDSA cycles improved the rate of appropriate duration antibiotics, and follow-up phone calls suggested no difference in satisfaction or need for nonroutine follow-up care based on prescription length. The next steps involve developing an order set and implementing individualized feedback.

Post-acute sensory neurological sequelae in patients with severe acute respiratory syndrome coronavirus 2 infection: the COVID-PN observational cohort study.

ABSTRACT: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can cause neurological sequelae after the resolution of symptomatic COVID-19 illness, but the occurrence of peripheral neuropathy symptoms and cranial nerve dysfunction is unknown. This study aimed to characterize the occurrence and severity of pain and peripheral neuropathy symptoms in patients with SARS-CoV-2 infection. An observational cohort study included adults tested for a SARS-CoV-2 infection at an academic medical center (assigned as CV+ or control, based on test results). Thirty to 90 days after the index SARS-CoV-2 test, patients completed a web-based questionnaire assessing pain, peripheral neuropathy-related sensory symptoms, and symptoms in the distribution of cranial nerves (current symptoms, symptoms at testing and 2 weeks thereafter). Univariate analyses compared the outcomes between the groups. Multivariable analysis was used to determine the odds for neuropathy symptoms after adjusting for key baseline variables. A total of 1556 participants were included: 542 CV+ patients and 1014 control subjects. CV+ patients reported a higher occurrence of peripheral neuropathy symptoms in the extremities anytime within 90 days postinfection (28.8% vs 12.9%, odds ratio [OR] [95% confidence interval] = 2.72 [2.10-3.54]), as well as such symptoms persisting up to 90 days after infection (6.1% vs 1.9%, OR = 3.39 [1.91-6.03]). The occurrence of pain in the extremities was higher in the CV+ group (24.2% vs 9.8%, OR = 2.95 [2.21-3.91]). SARS-CoV-2 infection was also associated with higher occurrence of peripheral neuropathy symptoms, after adjusting for the history of chronic pain and neuropathy (OR = 3.19 [2.37-4.29]). The results suggest that SARS-CoV-2 infection was independently associated with an increased risk of pain and peripheral neuropathy symptoms.

Cohort study protocol to characterize the incidence and severity of neuropathic pain in patients with severe acute respiratory syndrome coronavirus 2 infection.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has resulted in patients experiencing symptoms that include neurological dysfunction. As many viral infections are associated with neuropathy, the aim of the study is to characterize the incidence and severity of neuropathic pain in patients with COVID-19. METHODS: A cohort study will be conducted in adult (≥18 years) patients who were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at Washington University/Barnes-Jewish Hospital. Participants who are deceased, with incomplete test results, or who cannot be contacted will be excluded. Approximately 1320 participants will be recruited in a 1:2 ratio of those with a positive-to-negative SARS-CoV-2 test result. Each participant will be invited to complete a survey to assess their symptoms related to neuropathy, 30 to 90 days after their initial SARS-CoV-2 test. Survey responses, demographics, and clinical data from the electronic health record will be used for analysis. The primary outcome is the incidence of new symptoms of neuropathic pain. The self-reported DN4 and Neuropathic Pain Symptom Inventory questionnaires (Appendix 1, http://links.lww.com/PR9/A103) will be used for neuropathic pain screening and severity assessment, respectively. Exploratory analyses will be performed to investigate other potential clinical endpoints and trends. RESULTS/CONCLUSION: Similar to previous coronavirus infections, an increased incidence of new-onset neuropathic pain after COVID-19 disease is expected, along with an increase in the severity experienced by patients with COVID-19 with pre-existing chronic pain. Comprehensive understanding of how COVID-19 affects the nervous system can provide a better framework for managing pain in this disease.

Endogenous carbon monoxide production by menadione.

INTRODUCTION: Smokers have a significantly decreased risk of pre-eclampsia (PE), possibly attributed to an increase in blood carbon monoxide (CO) concentrations. At physiological concentrations, CO has been demonstrated to have placental vasodilatory and anti-inflammatory properties. Increasing endogenous CO production may have therapeutic potential to either prevent or treat PE. Menadione (MD), synthetic vitamin K3, increases CO in rat microsomes. Our objective was to investigate MD's ability to increase endogenous CO concentrations in pregnancy. METHODS: Three experiments were completed. First, in vitro CO production was measured using isolated GD15 placentas. Second, non-pregnant normotensive mice received no, 1.5, 4.0 or 6.5 g/L MD for 7 days. Lastly, pregnant normotensive mice received either no or 6.5 g/L MD in water from GD10.5 to GD17.5. Consumption was measured as average daily water intake per gram of body weight. Maternal and fetal CO levels in the blood and tissue were quantified using headspace gas chromatography. RESULTS: MD significantly increased CO production in isolated GD15 placentas. In both pregnant and non-pregnant experiments, splenic CO, hepatic CO, and splenic mass were higher in treated mice compared to controls (all p < 0.05). Maternal %COHb and Hb in treated dams were not significantly different compared to controls. The fetal:placental mass ratio was significantly lower in the treatment group (p = 0.002). DISCUSSION: Placental CO production was observed in GD15 placentas after co-incubation with MD. MD administration increased CO in the liver and spleens of pregnant mice. Further investigation into different doses of MD is required to identify one without demonstrable fetal/placental effects.