Firearm Safety Screening in the Pediatric Hospital Setting: A Quality Improvement Initiative.

Background: Firearm injuries are a leading cause of morbidity and mortality for US youth. Secure storage is protective against firearm injuries in children. Despite this evidence and national recommendations, rates of firearm safety screening among pediatric providers are low, particularly in the inpatient setting. Therefore, we aimed to increase the frequency of firearm safety screening among patients admitted to the Pediatric Hospital Medicine service. Methods: This project occurred in a tertiary pediatric hospital with a medium-sized pediatric residency program. The initial intervention was a firearm safety screening tool embedded into the electronic health record history and physical note template. Subsequent interventions included nursing education, monthly reminder emails, and gun violence discussions during intern orientation. Patients who screened positive were provided with educational materials and a free gun lock. Data collection occurred by chart review to determine the frequency of screening documentation in the H&P. A survey was also conducted among pediatric residents to identify persistent barriers to screening. Results: The percentage of inpatient firearm safety screening increased from 0.01% to 39% over 25 months, with a centerline shift noted after 2 months. Residents cited a lack of time with the patient and a belief that it was not the appropriate time to screen as persistent barriers to screening. Conclusions: This study identified an effective approach to improving firearm safety screening in an academic pediatric hospital. Hospitalization represents a unique opportunity for firearm safety screening and counseling, and inpatient providers should feel empowered to intervene in this setting.

Access to Firearms: Initiation of Firearm Screening Among Psychiatric Patients in a Pediatric Emergency Department.

OBJECTIVE: Increase provider screening rates for firearm access among patients presenting to the pediatric emergency department (PED) for a psychiatric chief complaint. METHODS: In this resident-driven quality improvement project, a retrospective chart review examined firearm access screening rates among patients presenting to the PED with the chief complaint of "psychiatric evaluation." After establishing our baseline screening rate, the first phase of our plan, do, study, act (PDSA) cycle included implementing Be SMART education for pediatric residents. We made Be SMART handouts available in the PED, created electronic medical record (EMR) templates to facilitate documentation, and emailed routine reminders to residents during their PED block. In the second PDSA cycle, the pediatric emergency medicine (PEM) fellows expanded our efforts to increase project awareness from a supervisory role. RESULTS: The baseline screening rate was 14.7% (50 of 340). After PDSA 1, a center line shift occurred, and screening rates increased to 34.3% (297 of 867). After PDSA 2, screening rates increased to 35.7% (226 of 632). In the intervention phase, providers who received training screened 39.5% (238 of 603) of encounters versus providers who did not receive training screened 30.8% (276 of 896) of encounters. Of all encounters screened, 39.2% (205 of 523) screened positive for in-home firearms. CONCLUSIONS: We improved firearm access screening rates in the PED using provider education, EMR prompts, and PEM fellow participation. Opportunities remain to promote firearm access screening and secure storage counseling in the PED.

A Case Report of Baclofen Toxicity in a Pediatric Patient With Normal Kidney Function Successfully Treated With Hemodialysis.

RATIONALE: Baclofen is a commonly prescribed medication used to decrease spasticity in children with cerebral palsy. Despite its widespread use, this medication has not demonstrated to be consistently effective in clinical studies. Baclofen is also associated with systemic adverse effects due to potent neuronal depression. The management of baclofen toxicity is mainly supportive; however, some studies have shown that hemodialysis may alleviate the symptoms of an overdose and shorten the recovery time. PRESENTING CONCERNS: In this case report, a 6-year-old boy with mild cerebral palsy, neuromyelitis optica, and normal kidney function was found unresponsive at home, with altered mental status, after ingesting 1300 mg of baclofen unobserved. The patient was intubated and mechanically ventilated because of significant neurologic depression with subsequent respiratory failure. DIAGNOSIS: The patient was diagnosed with baclofen-induced encephalopathy. An elevated serum baclofen level of 4.00 µg/mL (therapeutic range of 0.08-0.40 µg/mL) was observed 10 hours after he was found unresponsive. The patient's respiratory status deteriorated; he had high ventilatory requirements and remained comatose. INTERVENTION: With the worsening of his clinical condition in the intensive care unit, hemodialysis, administered via a high-efficiency high-flux dialyzer, was initiated approximately 18 hours after he was found unresponsive. The patient underwent 2 hemodialysis runs spaced 9 hours apart, with blood flow rates approaching 250 mL/min. OUTCOMES: Within 3 hours of the first hemodialysis treatment, the patient started to regain consciousness. He was extubated to room air 6 hours after the second hemodialysis treatment. NOVEL FINDINGS: Supportive management is the primary treatment of baclofen toxicity in a pediatric patient with normal kidney function. Hemodialysis may be considered in severe cases of baclofen toxicity and worsening clinical status, but further studies are needed to confirm this finding.

JUSTIFICATION: Le baclofène est un médicament couramment prescrit pour réduire la spasticité chez les enfants atteints de paralysie cérébrale. Malgré son usage répandu, l'efficacité du baclofène n'a pas été démontrée de façon constante dans les études cliniques. Ce médicament est également associé à des effets secondaires systémiques en raison d'une forte dépression neuronale. La gestion de la toxicité du baclofène consiste principalement en un traitement de soutien. Certaines études ont toutefois démontré que l'hémodialyse pourrait atténuer les symptômes d'une surdose et hâter la convalescence. PRÉSENTATION DU CAS: Nous présentons les cas d'un garçon de six ans atteint d'une légère paralysie cérébrale et d'une neuromyélite optique. L'enfant, dont la fonction rénale était normale, avait été retrouvé inconscient à son domicile, avec un état mental altéré, après avoir ingéré accidentellement 1 300 mg de baclofène. L'importante dépression neurologique et l'insuffisance respiratoire subséquente ont nécessité l'intubation et la ventilation mécanique du patient. DIAGNOSTIC: Une encéphalopathie induite par le baclofène a été diagnostiquée. Un taux très élevé de baclofène sérique, soit de 4,00 µg/mL (l'intervalle thérapeutique se situe entre 0,08 et 0,40 µg/mL), a été observé dix heures après que l'enfant ait été retrouvé inconscient. Le patient demeurait comateux, son état respiratoire s'était dégradé et ses besoins ventilatoires étaient très élevés. INTERVENTIONS: À l'unité des soins intensifs, la dégradation de l'état clinique a nécessité l'amorce d'un traitement d'hémodialyse environ 18 heures après que l'enfant ait été retrouvé inconscient. Le traitement a été administré à l'aide d'un filtre avec une membrane à haute efficacité et à haute perméabilité. Le patient a subi deux séances d'hémodialyse à neuf heures d'intervalle, avec un débit sanguin approchant les 250 mL/min. RÉSULTATS: L'enfant a lentement repris conscience moins de trois heures après le début du premier traitement d'hémodialyse, et a été extubé six heures après le deuxième traitement d'hémodialyse. NOUVEAUX RÉSULTATS: Le principal traitement dans le cas d'une intoxication au baclofène chez un enfant avec une fonction rénale normale est la prise en charge symptomatique. L'hémodialyse pourrait être envisagée en cas d'intoxication grave avec dégradation de l'état clinique. D'autres études sont toutefois nécessaires pour confirmer ce résultat.

Vapor-phase metalation by atomic layer deposition in a metal-organic framework.

Metal-organic frameworks (MOFs) have received attention for a myriad of potential applications including catalysis, gas storage, and gas separation. Coordinatively unsaturated metal ions often enable key functional behavior of these materials. Most commonly, MOFs have been metalated from the condensed phase (i.e., from solution). Here we introduce a new synthetic strategy capable of metallating MOFs from the gas phase: atomic layer deposition (ALD). Key to enabling metalation by ALD In MOFs (AIM) was the synthesis of NU-1000, a new, thermally stable, Zr-based MOF with spatially oriented -OH groups and large 1D mesopores and apertures.