The Rounds Efficiency Index: A Novel Physics-Based Construct for Patient- and Family-Centered Rounds.

BACKGROUND AND OBJECTIVES: Efficiently conducting patient- and family-centered rounds (PFCR) is challenging, particularly without a measure of efficiency. In physics, efficiency is the ratio of work output to work input. We sought to evaluate PFCR efficiency via a novel construct rooted in physics. Our objectives were to (1) Establish baseline work output for clinical work (CW), educational effectiveness (EE), and family experience (FE); (2) establish baseline work input for rounds length (RL); and (3) begin preliminary construction of a rounds efficiency index (REI) as a measure of PFCR efficiency. METHODS: Four components of rounds efficiency were collected on 5 inpatient acute care teams during a baseline period. CW consisted of the percentage of daily orders placed on rounds. EE was assessed via survey for trainees and FE by families. RL was recorded in minutes per patient. During an 8-week intensive period, the REI (reported as %) was calculated as a ratio of work output/work input using aggregate mean/median ratings for CW, EE, FE, and RL. RESULTS: Baseline data included 809 orders, 28 EE ratings, 21 FE ratings, and RL mean of 11.4 minutes per patient. During the intensive period, the median team-specific weekly REI for the end versus beginning of the academic year was 58% and 52.5% (P = .17), respectively. The median REI during the start and end of the block was 49% and 57% (P = .15), respectively. CONCLUSIONS: The study assessed 4 components of efficiency (CW, EE, FE, RL) and calculated REI allowing for a preliminary tool to measure rounding efficiency. With this, targeted interventions can improve PFCR efficiency.

Development of a COVID-19 Vulnerability Index (CVI) for the Counties and Residents of New Jersey, USA.

The coronavirus disease 2019, or COVID-19, has impacted countless aspects of everyday life since it was declared a global pandemic by the World Health Organization in March of 2020. From societal to economic impacts, COVID-19 and its variants will leave a lasting impact on our society and the world. During the height of the pandemic, it became increasingly evident that indices, such as the Center for Disease Control's (CDC) Social Vulnerability Index (SVI), were instrumental in predicting vulnerabilities within a community. The CDC's SVI provides important estimates on which communities will be more susceptible to 'hazard events' by compiling a variety of data from the U.S. Census and the American Community Survey. The CDC's SVI does not directly consider the susceptibility of a community to a global pandemic, such as the COVID-19 pandemic, due to the four themes and 15 factors that contribute to the index. Thus, the objective of this research is to develop a COVID-19 Vulnerability Index, or CVI, to evaluate a community's susceptibility to future pandemics. With 15 factors considered for CDC's SVI, 26 other factors were also considered for the development of the CVI that covered themes such as socioeconomic status, environmental factors, healthcare capacity, epidemiological factors, and disability. All factors were equally weighted to calculate the CVI based on New Jersey. The CVI was validated by comparing index results to real-world COVID-19 data from New Jersey's 21 counties and CDC's SVI. The results present a stronger positive linear relationship between the CVI and the New Jersey COVID-19 mortality/population and infection/population than there is with the SVI. The results of this study indicate that Essex County has the highest CVI, and Hunterdon County has the lowest CVI. This is due to factors such as disparity in wealth, population density, minority status, and housing conditions, as well as other factors that were used to compose the CVI. The implications of this research will provide a critical tool for decision makers to utilize in allocating resources should another global pandemic occur. This CVI, developed through this research, can be used at the county, state, and global levels to help measure the vulnerability to future pandemics.

NOD1 cooperates with HAX-1 to promote cell migration in a RIPK2- and NF-ĸB-independent manner.

The human Nod-like receptor protein NOD1 is a well-described pattern-recognition receptor (PRR) with diverse functions. NOD1 associates with F-actin and its protein levels are upregulated in metastatic cancer cells. A hallmark of cancer cells is their ability to migrate, which involves actin remodelling. Using chemotaxis and wound healing assays, we show that NOD1 expression correlated with the migration rate and chemotactic index in the cervical carcinoma cell line HeLa. The effect of NOD1 in cell migration was independent of the downstream kinase RIPK2 and NF-ĸB activity. Additionally, NOD1 negatively regulated the phosphorylation status of cofilin, which inhibits actin turnover. Co-immunoprecipitation assays identified HCLS1-associated protein X-1 (HAX-1) as a previously unknown interaction partner of NOD1. Silencing of HAX-1 expression reduced the migration behaviour to similar levels as NOD1 knockdown, and simultaneous knockdown of NOD1 and HAX-1 showed no additive effect, suggesting that both proteins act in the same pathway. In conclusion, our data revealed an important role of the PRR NOD1 in regulating cell migration as well as chemotaxis in human cervical cancer cells and identified HAX-1 as a protein that interacts with NOD1 and is involved in this signalling pathway.

NOD-like Receptors-Emerging Links to Obesity and Associated Morbidities.

Obesity and its associated metabolic morbidities have been and still are on the rise, posing a major challenge to health care systems worldwide. It has become evident over the last decades that a low-grade inflammatory response, primarily proceeding from the adipose tissue (AT), essentially contributes to adiposity-associated comorbidities, most prominently insulin resistance (IR), atherosclerosis and liver diseases. In mouse models, the release of pro-inflammatory cytokines such as TNF-alpha (TNF-α) and interleukin (IL)-1ß and the imprinting of immune cells to a pro-inflammatory phenotype in AT play an important role. However, the underlying genetic and molecular determinants are not yet understood in detail. Recent evidence demonstrates that nucleotide-binding and oligomerization domain (NOD)-like receptor (NLR) family proteins, a group of cytosolic pattern recognition receptors (PRR), contribute to the development and control of obesity and obesity-associated inflammatory responses. In this article, we review the current state of research on the role of NLR proteins in obesity and discuss the possible mechanisms leading to and the outcomes of NLR activation in the obesity-associated morbidities IR, type 2 diabetes mellitus (T2DM), atherosclerosis and non-alcoholic fatty liver disease (NAFLD) and discuss emerging ideas about possibilities for NLR-based therapeutic interventions of metabolic diseases.

Respiratory Outcomes for Ventilator-Dependent Children With Bronchopulmonary Dysplasia.

OBJECTIVES: To describe outpatient respiratory outcomes and center-level variability among children with severe bronchopulmonary dysplasia (BPD) who require tracheostomy and long-term mechanical ventilation. METHODS: Retrospective cohort of subjects with severe BPD, born between 2016 and 2021, who received tracheostomy and were discharged on home ventilator support from 12 tertiary care centers participating in the BPD Collaborative Outpatient Registry. Timing of key respiratory events including time to tracheostomy placement, initial hospital discharge, first outpatient clinic visit, liberation from the ventilator, and decannulation were assessed using Kaplan-Meier analysis. Differences between centers for the timing of events were assessed via log-rank tests. RESULTS: There were 155 patients who met inclusion criteria. Median age at the time of the study was 32 months. The median age of tracheostomy placement was 5 months (48 weeks' postmenstrual age). The median ages of hospital discharge and first respiratory clinic visit were 10 months and 11 months of age, respectively. During the study period, 64% of the subjects were liberated from the ventilator at a median age of 27 months and 32% were decannulated at a median age of 49 months. The median ages for all key events differed significantly by center (P ≤ .001 for all events). CONCLUSIONS: There is wide variability in the outpatient respiratory outcomes of ventilator-dependent infants and children with severe BPD. Further studies are needed to identify the factors that contribute to variability in practice among the different BPD outpatient centers, which may include inpatient practices.

The diverse role of heparan sulfate and other GAGs in SARS-CoV-2 infections and therapeutics.

In December 2019, the global coronavirus disease 2019 (COVID-19) pandemic began in Wuhan, China. COVID-19 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which infects host cells primarily through the angiotensin-converting enzyme 2 (ACE2) receptor. In addition to ACE2, several studies have shown the importance of heparan sulfate (HS) on the host cell surface as a co-receptor for SARS-CoV-2-binding. This insight has driven research into antiviral therapies, aimed at inhibiting the HS co-receptor-binding, e.g., by glycosaminoglycans (GAGs), a family of sulfated polysaccharides that includes HS. Several GAGs, such as heparin (a highly sulfated analog of HS), are used to treat various health indications, including COVID-19. This review is focused on current research on the involvement of HS in SARS-CoV-2 infection, implications of viral mutations, as well as the use of GAGs and other sulfated polysaccharides as antiviral agents.

NLRC5 affects diet-induced adiposity in female mice and co-regulates peroxisome proliferator-activated receptor PPARγ target genes.

Nucleotide-binding and oligomerization domain containing 5 (NLRC5) is the key transcriptional regulator of major histocompatibility (MHC) class I genes. Recent observations suggest a role for NLRC5 in metabolic traits and in transcriptional regulation beyond MHC class I genes. To understand the function of NLRC5 in metabolic disease, we subjected Nlrc5 -/- mice to high-fat diet (HFD) feeding. Female Nlrc5 -/- mice presented with higher weight gain and more adipose tissue (AT) compared to wild-type (WT) animals. Mechanistically, we demonstrate that NLRC5 enhanced the expression of peroxisome proliferator-activated receptor (PPAR) γ target genes in human cells. We identify Sin3A and negative elongation factor (NELF) B as two novel NLRC5 interaction partners and show that Sin3A partly modulates the synergistic transcriptional effect of NLRC5 on PPARγ. Collectively, we show that NLRC5 contributes to weight gain in mice, which involves transcriptional enhancement of PPARγ targets by NLRC5 that is co-regulated by Sin3A.

Using Electronic Health Record Modifications to Increase Use of Adolescent Sensitive Notes.

OBJECTIVES: Confidentiality is imperative when caring for adolescents, yet the 21st Century Cures Act ensures guardian access to some of their child's documentation. Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, whereas adolescent sensitive notes (ASN) are not. Our aim was to decrease sexual history and substance use (SHSU) documentation in H&P notes. METHODS: This quality improvement study included adolescents ages 13 to 17 from August 1, 2020 to May 31, 2021. Interventions included disappearing help text added to PHM H&P template prompting placement of positive SHSU in the ASN, editing of disappearing help text to encourage copy and paste of all SHSU into ASN, and communication to providers. The primary outcome measure was documentation of SHSU in H&P notes. The process measure was presence of ASNs. The balancing measures were documentation of unapproved social history domains in the ASN and encounters with no SHSU documentation. Statistical process control was used for analysis. RESULTS: Four hundred fifty patients were included in this analysis. There was decreased documentation of SHSU within H&P notes from means of 58.4% and 50.4% to 8.4% and 11.4%, respectively. There was increased utilization of ASN from 22.8% to 72.3%. Special cause variation occurred. Other unapproved domains in the ASN decreased. Encounters with no SHSU were unchanged. CONCLUSIONS: The quality improvement intervention of disappearing help text in PHM H&Ps was associated with decreased documentation of SHSU within H&P notes and increased utilization of ASN. This simple intervention helps maintain confidentiality. Further interventions may include utilization of disappearing help text in other specialties.

Validation of an outpatient questionnaire for bronchopulmonary dysplasia control.

INTRODUCTION: Despite bronchopulmonary dysplasia (BPD) being a common morbidity of preterm birth, there is no validated objective tool to assess outpatient respiratory symptom control for clinical and research purposes. METHODS: Data were obtained from 1049 preterm infants and children seen in outpatient BPD clinics of 13 US tertiary care centers from 2018 to 2022. A new standardized instrument was modified from an asthma control test questionnaire and administered at the time of clinic visits. External measures of acute care use were also collected. The questionnaire for BPD control was validated in the entire population and selected subgroups using standard methodology for internal reliability, construct validity, and discriminative properties. RESULTS: Based on the scores from BPD control questionnaire, the majority of caregivers (86.2%) felt their child's symptoms were under control, which did not differ by BPD severity (p = 0.30) or a history of pulmonary hypertension (p = 0.42). Across the entire population and selected subgroups, the BPD control questionnaire was internally reliable, suggestive of construct validity (albeit correlation coefficients were -0.2 to -0.4.), and discriminated control well. Control categories (controlled, partially controlled, and uncontrolled) were also predictive of sick visits, emergency department visits, and hospital readmissions. CONCLUSION: Our study provides a tool for assessing respiratory control in children with BPD for clinical care and research studies. Further work is needed to identify modifiable predictors of disease control and link scores from the BPD control questionnaire to other measures of respiratory health such as lung function testing.

Prumnopitys Andina Fruit Extract Activates Liver X Receptors after In Vitro Digestion.

SCOPE: 20-Hydroxyecdysone (20E) is the main phytochemical present in the fresh arils of Prumnopitys andina. 20E is reported to have anabolic effects by modulation of gene transcription by interaction with nuclear receptors. Our aim is to evaluate the in vitro bioaccessibility, transepithelial transport of 20E, and the capacity of P. andina fruit extract and 20E to activate selected mammalian nuclear receptors in transiently transfected human cells after simulated gastrointestinal digestion. RESULTS: 20E shows good stability, solubility, and micellization after in vitro digestion. 20E is taken up by Caco-2 cells, but poorly transported through the epithelial cell membrane, possibly due to P-glycoprotein-mediated efflux. In transiently transfected HepG2 cells, the fruit extract significantly induces the signal intensity for the liver X receptor (LXR)-α and -ß by 1.6 and 1.4-fold, respectively. In contrast, the treatment with 20E, irrespective of its concentration, did not change the activity of both LXR receptors. No effects are observed for the pregnane X receptor or the constitutive androstane receptor. CONCLUSION: Our findings show that components of the digested P. andina extract other than 20E are responsible for the effects on LXR-α and -ß. Our findings open new perspectives on the potential role of P. andina fruits in cholesterol metabolism and inflammatory diseases.

Overweight Infants Hospitalized for Bronchiolitis Associated With Severe Disease.

OBJECTIVES: Overweight negatively affects pediatric respiratory function. In this study, we evaluate if overweight is associated with more severe bronchiolitis in hospitalized infants. METHODS: This retrospective cohort study analyzed infants aged 30 to 365 days hospitalized for bronchiolitis from September 2019 to April 2020. Exclusion criteria included known risk factors for severe bronchiolitis, asthma treatment, or bacterial pneumonia. Weight-for-length z-score was categorized per the World Health Organization's growth assessments as overweight (z-score >2), underweight (z-score <-2), and standard weight (between -2 and ≤2). Primary outcomes included respiratory support, ICU stay, and local bronchiolitis score. Secondary outcomes included supplemental interventions. RESULTS: After exclusion criteria, 385 of 644 infants were categorized as overweight (n = 24), standard (n = 335), or underweight (n = 26). There were differences in need for respiratory support (overweight, 100%; standard weight, 81.8%; underweight, 76.9%; P = .03), highest support of high-flow nasal cannula (overweight, 75%; standard weight, 48%; underweight, 42%; P = .03), admission to ICU (overweight, 54.2%; standard weight, 21.5%; underweight, 34.7%; P < .001), and median bronchiolitis score (overweight, 8 [interquartile range 5-10]; standard weight, 4 [3-7]; underweight, 4 [3-7]; P = .01). Findings remained significant after age adjustments. Additionally, overweight experienced higher frequency of certain treatments. CONCLUSIONS: This study suggests overweight is associated with more severe bronchiolitis in hospitalized infants supported by increased respiratory support level, bronchiolitis scores, and interventions. Higher need for ICU admission may be related to high-flow nasal cannula limitations on the acute care floor.

Approaches to Interdisciplinary Care for Infants with Severe Bronchopulmonary Dysplasia: A Survey of the Bronchopulmonary Dysplasia Collaborative.

OBJECTIVE: Bronchopulmonary dysplasia (BPD) remains the most common late morbidity for extremely premature infants. Care of infants with BPD requires a longitudinal approach from the neonatal intensive care unit to ambulatory care though interdisciplinary programs. Current approaches for the development of optimal programs vary among centers. STUDY DESIGN: We conducted a survey of 18 academic centers that are members of the BPD Collaborative, a consortium of institutions with an established interdisciplinary BPD program. We aimed to characterize the approach, composition, and current practices of the interdisciplinary teams in inpatient and outpatient domains. RESULTS: Variations exist among centers, including composition of the interdisciplinary team, whether the team is the primary or consult service, timing of the first team assessment of the patient, frequency and nature of rounds during the hospitalization, and the timing of ambulatory visits postdischarge. CONCLUSION: Further studies to assess long-term outcomes are needed to optimize interdisciplinary care of infants with severe BPD. KEY POINTS: · Care of infants with BPD requires a longitudinal approach from the NICU to ambulatory care.. · Benefits of interdisciplinary care for children have been observed in other chronic conditions.. · Current approaches for the development of optimal interdisciplinary BPD programs vary among centers..

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls.

Postdischarge phone calls (PDPCs) are recommended to identify and mitigate postdischarge issues such as missed follow-up appointments, medication errors, and failure to activate contingency plans. A current state assessment showed variability in documenting PDPC content and postdischarge issue mitigation. Therefore, the primary aim was to improve the postdischarge issue mitigation documentation rate from 65% to 100% over 16 months. Methods: An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. Results: The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Conclusions: Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Pediatric Respiratory Illness Hospitalizations Prior to COVID-19 and During the First Year of the COVID-19 Pandemic in Southeast Wisconsin.

BACKGROUND: Public health measures combatting the COVID-19 pandemic also led to a decrease in other pediatric respiratory illnesses. We describe the local pattern of pediatric respiratory hospitalizations in southeast Wisconsin prior to COVID-19 and during the first year of the pandemic. METHODS: We performed a cross-sectional examination of hospitalizations for asthma, bronchiolitis, and bacterial pneumonia at a single tertiary children's hospital prior to COVID-19 through the first year of the COVID-19 pandemic. RESULTS: We found a significant decrease in the average monthly hospitalization rates prior to and during COVID-19 for asthma, bronchiolitis, and bacterial pneumonia (P < 0.001), with average percent decrease of hospitalizations per month of 48%, 78%, and 47.7%, respectively. CONCLUSIONS: The decrease in hospitalizations is likely multifactorial and related to public health measures, behavior changes, and other epidemiological factors.

An Opportunity in Cancer Prevention: Human Papillomavirus Vaccine Delivery in the Hospital.

OBJECTIVE: Pediatric hospitalizations are a missed opportunity for delivery of the human papilloma virus (HPV) vaccination. In this study, the authors' aim was to increase HPV vaccination rates among adolescents cared for by the pediatric hospital medicine (PHM) service at our academic children's hospital. METHODS: This quality improvement (QI) study included adolescents ≥13 years who were discharged from PHM. Interventions included: modification of discharge order sets to include vaccination status and provider training seminars regarding the delivery of the HPV vaccine. Follow-up materials were distributed to providers by e-mail. The primary outcome measure was adolescent HPV vaccination rates. Secondary outcome measures were adolescent meningococcal vaccination rates and accuracy of immunization status documentation. The balancing measure was length of stay (LOS). Data were collected via chart review. Statistical process control charts were used to analyze for special cause variation. RESULTS: From May 2019 through February 2020, 440 patients were included in this analysis. Throughout the study, HPV and meningococcal vaccination rates increased from a baseline median of 4.6% to 21.2% and 8.3% to 26.6%, respectively. HPV vaccination was not significantly associated with sex, HPV dose due, or admitting service. Accuracy of immunization status documentation and LOS remained unchanged. CONCLUSIONS: Using QI methodology we were successful in increasing HPV and meningococcal vaccination rates among hospitalized adolescents. Considering the relationship of these 2 vaccines is a potential topic of future work. Discerning the correct immunization status at time of admission may be a potential opportunity for improvement in future work.

Growth and nutrition in children with established bronchopulmonary dysplasia: A review of the literature.

BACKGROUND: Bronchopulmonary dysplasia (BPD) remains the most common late morbidity of preterm birth. Clinical care and research have largely focused on the pathogenesis and prevention of BPD. Preterm infants who develop BPD have significant medical needs that persist throughout their hospital course and continue after discharge, including those associated with growth and nutrition. The objective of this study was to review the available literature on nutrition and growth in infants with established BPD and to identify the knowledge and research gaps to provide direction for future studies. METHODS: We conducted a literature search in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using Ovid MEDLINE, CINAHL, and Embase. Titles, abstracts, and full texts were independently reviewed by the authors and selected based on predetermined inclusion/exclusion criteria. Results were summarized qualitatively. RESULTS: Excluding duplicates, 2315 articles were identified. Thirty articles were selected for inclusion. We identified the following key components of nutrition support and clinical care: energy expenditure, growth, and metabolism; body composition; enteral nutrition; supplements; parenteral nutrition; and respiratory outcomes. CONCLUSIONS: Despite a large body of literature describing the role of growth and nutrition in the prevention of BPD, research is lacking with respect to interventions and management in the population with established BPD. Thus, organized approaches for clinical interventions and trials with respect to growth and nutrition in infants and young children with established BPD are needed. These studies should include multiple centers because of the small numbers of patients with BPD at each site.

Using Quality Improvement Methodology to Increase Communication of Discharge Criteria on Rounds.

OBJECTIVE: Clear communication about discharge criteria with families and the interprofessional team is essential for efficient transitions of care. Our aim was to increase the percentage of pediatric hospital medicine patient- and family-centered rounds (PFCR) that included discharge criteria discussion from a baseline mean of 32% to 75% over 1 year. METHODS: We used the Model for Improvement to conduct a quality improvement initiative at a tertiary pediatric academic medical center. Interventions tested included (1) rationale sharing, (2) PFCR checklist modification, (3) electronic discharge SmartForms, (4) data audit and feedback and (5) discharge criteria standardization. The outcome measure was the percentage of observed PFCR with discharge criteria discussed. Process measure was the percentage of PHM patients with criteria documented. Balancing measures were rounds length, length of stay, and readmission rates. Statistical process control charts assessed the impact of interventions. RESULTS: We observed 700 PFCR (68 baseline PFCR from July to August 2019 and 632 intervention period PFCR from November 2019 to June 2021). At baseline, discharge was discussed during 32% of PFCR. After rationale sharing, checklist modification, and criteria standardization, this increased to 90%, indicating special cause variation. The improvement has been sustained for 10 months.At baseline, there was no centralized location to document discharge criteria. After development of the SmartForm, 21% of patients had criteria documented. After criteria standardization for common diagnoses, this increased to 71%. Rounds length, length of stay, and readmission rates remained unchanged. CONCLUSION: Using quality improvement methodology, we successfully increased verbal discussions of discharge criteria during PFCR without prolonging rounds length.