Impact of concurrent glomerulonephritis on outcomes of diffuse alveolar haemorrhage in antineutrophil cytoplasmic antibody-associated vasculitis.

OBJECTIVES: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) commonly presents with diffuse alveolar haemorrhage (DAH) and/or glomerulonephritis. Patients who present with DAH but without kidney involvement have been understudied. METHODS: Patients with DAH diagnosed by bronchoscopy and attributed to AAV over 8.5 years were retrospectively identified through electronic medical records and bronchoscopy reporting software. Patients with end-stage kidney disease (ESKD) or prior kidney transplant were excluded. Characteristics, treatments, and outcomes were abstracted. RESULTS: 30 patients were identified with DAH secondary to AAV. Five with ESKD or prior kidney transplant, and one with concomitant anti-glomerular basement membrane disease, were excluded, leaving 24 patients for analysis. At the time of qualifying bronchoscopy, six patients had no apparent kidney involvement by AAV, while eight of 18 with kidney involvement required dialysis. Of the eight patients dialysed during the initial hospitalisation, four were declared to have ESKD and three died in the subsequent year (one of whom did both). None of the 16 patients without initial dialysis requirement developed kidney involvement requiring dialysis in the subsequent year, though three of the six without initial evidence of kidney involvement by AAV ultimately developed it. No patient without initial kidney involvement died during follow-up. CONCLUSIONS: In our cohort, patients with DAH due to AAV without initial kidney involvement did not develop kidney involvement requiring dialysis or die during the follow-up period, though half of patients without initial evidence of kidney involvement subsequently developed it. Larger studies are warranted to better characterise this population and guide medical management.

Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With Other Healthcare Team Members.

OBJECTIVES: Graduate medical education (GME) trainees have a unique perspective from which to identify and report patient safety concerns. However, it is not known how safety reports submitted by GME trainees differ from those submitted by other clinical staff. We hypothesized that GME trainees were more likely to submit safety reports regarding transitions of care, delays in care, and lapses in communication, and reports of higher severity compared with other frontline staff such as nurses, pharmacists, and other providers. METHODS: Patient safety reports submitted by clinical staff for 1 year at an academic tertiary care children's hospital were retrospectively reviewed and categorized by reporter type. Severity level and event type were analyzed by reporter type, and repeat χ2 tests were used to compare the percentage of reports at each severity level and in each event type submitted by GME trainees compared with each other reporter type. RESULTS: Graduate medical education trainees submitted reports of greater severity (level E/F/G) compared with nurses (10% versus 5%, P = 0.021) and pharmacists (10% versus 2%, P = 0.001). A greater percent of GME trainees' reports were categorized as errors in transitions of care, diagnosis, ordering, laboratory collection, and care delays compared with several other reporter types. CONCLUSIONS: Graduate medical education trainees identify system vulnerabilities not detected by other personnel, supporting efforts to increase safety reporting by GME trainees.

Success of a Resident-Led Safety Council: A Model for Satisfying CLER Pathways to Excellence Patient Safety Goals.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) program focuses on aspects of the graduate medical education learning environment, such as patient safety. Data from CLER site visits reveal that many resident physicians do not receive adequate training on patient safety. OBJECTIVE: We evaluated a pediatric resident-led safety council as a method to meet CLER Pathways to Excellence patient safety objectives. METHODS: The Duke Pediatric Residency Safety Council (PRSC) created an infrastructure for residents to participate in department safety efforts, review safety events, and act as leaders for safety initiatives. Annual surveys were distributed to graduate medical education trainees through the institution's patient safety center and the PRSC. Survey results of safety attitudes were compared over time within the pediatrics program and between pediatrics and nonpediatrics trainees at the institution. Resident-submitted safety reports were tracked through an institutional safety event repository. RESULTS: From 2013 to 2017, the percentage of residents who strongly agreed that they could submit a safety report doubled (from 35% [6 of 17] to 73% [22 of 30], P = .011). The average number of safety reports submitted by a pediatrics resident per year did not significantly change during this period (from 3.0 to 3.8, P = .11). In 2017, 90% of pediatrics residents (27 of 30) agreed or strongly agreed that their concerns would be addressed if they entered a safety report. CONCLUSIONS: The council addressed 5 of the 7 CLER Pathways to Excellence in patient safety.

How does heart rate recovery after sub-maximal exercise correlate with maximal exercise testing in children with CF?

BACKGROUND: Disease progression in cystic fibrosis (CF) is marked by worsening exercise tolerance. Further, maximal exercise capacity (VO2 peak) correlates with survival in CF, but maximal tests are uncomfortable and resource-intensive. A three-minute step test (STEP) has been validated in CF. Heart rate (HR) recovery after exercise correlates with all-cause mortality in adult non-CF populations. We compared HR recovery after the three-minute step test with VO2 peak in children with CF. METHODS: Twenty-four children with CF performed STEP and a maximal exercise test. Correlation between the tests was assessed. RESULTS: Maximum HR on STEP was lower than on the maximal test (140 vs. 190, p<0.01). Peak HR during STEP correlated inversely with VO2 peak. In subjects with mild lung disease, faster HR recovery after STEP correlated with higher VO2 peak. CONCLUSIONS: The three-minute step test is a feasible submaximal test in this patient population. HR during and after a three-minute step test may reflect VO2 peak in children with CF.

Modulation of estrogen causes disruption of craniofacial chondrogenesis in Danio rerio.

Estrogen is a steroid hormone that is ubiquitous in vertebrates, but its role in cartilage formation has not been extensively studied. Abnormalities of craniofacial cartilage and bone account for a large portion of birth defects in the United States. Zebrafish (Danio rerio) have been used as models of human disease, and their transparency in the embryonic period affords additional advantages in studying craniofacial development. In this study, zebrafish embryos were treated with 17-ß estradiol (E2) or with an aromatase inhibitor and observed for defects in craniofacial cartilage. Concentrations of E2 greater than 2µM caused major disruptions in cartilage formation. Concentrations below 2µM caused subtle changed in cartilage morphology that were only revealed by measurement. The angles formed by cartilage elements in fish treated with 1.5 and 2µM E2 were increasingly wide, while the length of the primary anterior-posterior cartilage element in these fish decreased significantly from controls. These treatments resulted in fish with shorter, flatter faces as estrogen concentration increased. Inhibition of aromatase activity also resulted in similar craniofacial disruption indicating that careful control of estrogen signaling is required for appropriate development. Further investigation of the phenomena described in this study could lead to a better understanding of the etiology of craniofacial birth defects and endocrine disruption of cartilage formation.