Granulomas in Diagnostic Biopsies Associated With High Risk of Crohn's Complications-But May Be Preventable.

BACKGROUND: Granulomatous intestinal inflammation may be associated with aggressive Crohn's disease (CD) behavior. However, this has not been confirmed, and it is unknown if associated disease complications are preventable. METHODS: This is a retrospective cohort of patients younger than 21 years at CD diagnosis (November 1, 2005 to November 11, 2015). Clinical information was abstracted, including dates of starting medications and the timing of perianal fistula or stricture development, if any. Diagnostic pathology reports were reviewed, and a subset of biopsy slides were evaluated by a blinded pathologist. Patients were excluded if perianal fistula or stricture developed within 30 days after CD diagnosis. Medications were included in analyses only if started >90 days before development of perianal fistula or stricture. RESULTS: In total, 198 patients were included. Half (54%) had granulomas at diagnosis. Granulomas were associated with a greater than 3-fold increased risk of perianal fistula (hazard ration [HR] = 3.24; 95% confidence interval CI], 1.40-7.48). Immunomodulator and anti-tumor necrosis factor-α (anti-TNF) therapy were associated with 90% (HR, = 0.10; 95% CI, 0.03-0.42) and 98% (HR, = 0.02; 95% CI, 0.01-0.10) reduced risk of perianal fistula, respectively. Patients with granulomatous inflammation preferentially responded to anti-TNF therapy with reduced risk of perianal fistula. The presence of granulomas was not associated with risk of stricture. Immunomodulator and anti-TNF therapy were associated with 96% (HR, = 0.04; 95% CI, 0.01-0.22) and 94% (HR, = 0.06; 95% CI, 0.02-0.20) reduced risk of stricture, respectively. CONCLUSIONS: Granulomas are associated with increased risk of perianal fistula but not stricture. Steroid sparing therapies seem to reduce the risk of both perianal fistula and stricture. For those with granulomas, anti-TNF-α therapy greatly reduced the risk of perianal fistula development, whereas immunomodulators did not.

Utility of RSV rapid diagnostic assays in hospitalized children in Amman, Jordan.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of acute respiratory infections in children worldwide and a frequent cause of hospitalization. Rapid diagnostic assays (RDAs) are available for RSV and they help guide management; however, they are underutilized in developing countries. We compared molecular diagnostics to RSV RDA in hospitalized children in Amman, Jordan. MATERIALS AND METHODS: Children under 2 years of age, admitted with fever and/or respiratory symptoms were enrolled prospectively from March 2010 to 2012. Demographic and clinical data were collected through parent/guardian interviews and medical chart abstraction. RSV RDAs were performed, and nasal/throat swabs were tested for RSV using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). RESULTS: RSV RDA and PCR were performed on specimens from 1271 subjects. RSV RDA had a sensitivity of 26% and a specificity of 99%, with positive and negative predictive values of 98.6% and 43%, respectively. RDA-positive patients had fewer days of symptoms at presentation and were more likely to have a history of prematurity, lower birth weight, require supplemental oxygen, and a longer hospitalization as compared with subjects with negative RDA. Multivariate analysis showed only lower birth weight, lack of cyanosis on examination, and lower cycle threshold to be independently associated with positive RDA (p ≤ .001). CONCLUSION: RSV RDAs had high specificity, but low sensitivity as compared with qRT-PCR. Positive RDA was associated with patients with a more severe disease, as indicated by oxygen use, longer length of stay, and higher viral load. Implementation of RDAs in developing countries could be an inexpensive and expedient method for predicting RSV disease severity and guiding management.

Henoch-Schönlein Purpura-Associated Hemorrhagic Shock After Secondary Norovirus Infection.

Henoch-Schönlein purpura (HSP) is a small-vessel vasculitis, typically involving the skin, joints, kidneys, and gastrointestinal (GI) tract. Although GI bleeding with HSP can occur, massive GI hemorrhage is rare. It is well documented that HSP can be triggered by a preceding infection, often of the upper respiratory tract. Infections that occur after the development of HSP and trigger worsening of the disease or new complications have not been well reported. We present the case of a three-year-old previously healthy boy who developed HSP with typical signs and symptoms, including hematochezia that resolved after treatment with intravenous steroids. The patient then contracted norovirus and subsequently developed massive GI bleeding, leading to hemorrhagic shock and requiring admission to an intensive care unit. This case demonstrates that secondary infection, such as norovirus infection, can precipitate worsening of underlying HSP vasculitis and lead to acute clinical decompensation. Clinicians should be aware of the risk of acute clinical changes in patients with HSP.

Impact of a care delivery redesign initiative for vascular surgery.

OBJECTIVE: A hospital-wide quality improvement process through a care delivery redesign (CDR) was initiated to improve patient care efficiency, clinical documentation, and length of stay (LOS). The impact of CDR was assessed through LOS, unplanned readmission rates, and hospital financial metrics. METHODS: The CDR team consisted of the Chief of Vascular Surgery, inpatient nurse practitioner, dedicated case manager, clinical documentation improvement specialist, and vascular surgery residents and faculty. The nurse practitioner facilitated patient care coordination, resident system-based education, and multidisciplinary collaboration. Tools created to track performance and to ensure sustainability included daily discussions of patient care barriers and solutions; standardized order sets; a mobile app for residents containing resident service expectations, disease-specific resources, and vascular surgery journal links; and a weekly inpatient tracker showing real-time patient care data. Outcome measures included LOS, case mix index, contribution margin, and unplanned readmissions. Each outcome was determined for all inpatient admissions the year before and the 12 months after CDR was initiated. Outcomes were compared between the two groups. RESULTS: Implementation of CDR resulted in a 23% decrease in LOS (P = .003), reducing the gap to the Centers for Medicare and Medicaid Services geometric mean LOS from 2.1 days to 0.5 day (P < .001). Clinical documentation resulted in an increase in case mix index of 10% (P = .011). The 30-day unplanned readmission rates did not change in the 12 months after CDR was initiated compared with the year before (P = .92). Financial data demonstrated decreased variable cost and increased revenue resulting in a $1.89 million increase in contribution margin. CONCLUSIONS: A CDR predicated on a dedicated service line advanced practitioner, clinical documentation education, weekly service tracker review, and real-time management of system-related barriers to patient care is described. Implementation of the CDR reduced hospital LOS with no change in unplanned readmissions and provided significant financial benefit to the hospital by increasing revenue and decreasing variable cost.

Focused Resident Education and Engagement in Quality Improvement Enhances Documentation, Shortens Hospital Length of Stay, and Creates a Culture of Continuous Improvement.

PURPOSE: System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI. METHODS: Our vascular surgery service implemented several QI initiatives focused on decreasing length of stay (LOS) by targeting resident education and engagement. Residents were educated on terminology and processes impacting hospital and CMS QI metrics such as Medicare geometric mean LOS (CMS GMLOS) and diagnostic-related groups (DRG) with complication or comorbidity (CC/MCC) coding. LOS initiatives focused on identifying, tracking and removing avoidable perioperative delays, and improving accuracy of clinical documentation. Residents were given specific roles in QI initiatives and the impact on LOS was quantified. Patients' CMS GMLOS were compared to actual LOS during daily rounds, with confirmation that resident progress notes contained thorough and accurate documentation of diagnoses, comorbidities, and complications. Ten minutes during weekly preoperative conferences were dedicated to ongoing QI, with LOS metrics for the inpatient census presented by trainees and reviewed by attendings. Feedback was given addressing barriers to avoidable delays and impact on LOS. Data for July 2016-June 2017 (FY17) was compared to preimplementation baseline data (FY16) for vascular discharges overall. Accurate documentation of acuity was evaluated with in-depth review of notes and overall case mix index. RESULTS: Within the first year of implementation, overall vascular admissions demonstrated a 21% reduction in LOS, closing the gap between observed LOS and expected CMS GMLOS, from 2.1days to 0.5days on average. Documentation improved, with a shift in 24% of DRGs to accurately reflect CC/MCC. Overall case mix index increased by 10%, from 3.07 to 3.37. CONCLUSIONS: A culture of continuous quality improvement can be created with the establishment of a QI infrastructure that educates and involves trainees as stakeholders. Assigning discrete roles to increase resident accountability supports both formal and informal resident education that can substantially impact hospital benchmarking metrics.

Severe outcomes associated with respiratory viruses in newborns and infants: a prospective viral surveillance study in Jordan.

OBJECTIVE: To assess virus-specific hospitalisation rates, risk factors for illness severity and seasonal trends in children hospitalised with acute respiratory infections (ARI). DESIGN: Prospective cohort study. SETTING: A government hospital serving low-income and middle-income population in Amman, Jordan. PARTICIPANTS: Children under 2 years of age hospitalised with fever and/or respiratory symptoms (n=3168) from 16 March 2010 to 31 March 2013. Children with chemotherapy-associated neutropenia and newborns who had never been discharged after birth were excluded from the study. OUTCOME MEASURES: Hospitalisation rates and markers of illness severity: admission to intensive care unit (ICU), mechanical ventilation (MV), oxygen therapy, length of stay (LOS) and death. RESULTS: Of the 3168 subjects, 2581 (82%) had at least one respiratory virus detected, with respiratory syncytial virus (RSV) being the most predominant pathogen isolated. During admission, 1013 (32%) received oxygen therapy, 284 (9%) were admitted to ICU, 111 (4%) were placed on MV and 31 (1%) children died. Oxygen therapy was higher in RSV-only subjects compared with human rhinovirus-only (42%vs29%, p<0.001), adenovirus-only (42%vs21%, p<0.001) and human parainfluenza virus-only (42%vs23%, p<0.001) subjects. The presence of an underlying medical condition was associated with oxygen therapy (adjusted OR (aOR) 1.95, 95% CI 1.49 to 2.56), ICU admission (aOR 2.51, 95% CI 1.71 to 3.68), MV (aOR 1.91, 95% CI 1.11 to 3.28) and longer LOS (aOR1.71, 95% CI 1.37 to 2.13). Similarly, younger age was associated with oxygen therapy (0.23, 95% CI 0.17 to 0.31), ICU admission (aOR 0.47, 95% CI 0.30 to 0.74), MV (0.28, 95% CI 0.15 to 0.53) and longer LOS (aOR 0.47, 95% CI 0.38 to 0.59). Pneumonia was strongly associated with longer LOS (aOR 2.07, 95% CI 1.65 to 2.60), oxygen therapy (aOR 2.94, 95% CI 2.22 to 3.89), ICU admission (aOR 3.12, 95% CI 2.16 to 4.50) and MV (aOR 3.33, 95% CI 1.85 to 6.00). Virus-specific hospitalisation rates ranged from 0.5 to 10.5 per 1000 children. CONCLUSION: Respiratory viruses are associated with severe illness in Jordanian children hospitalised with ARI. Prevention strategies such as extended breast feeding, increased access to palivizumab and RSV vaccine development could help decrease hospitalisation rates and illness severity, particularly in young children with underlying medical conditions.

Vitamin D deficiency among newborns in Amman, Jordan.

OBJECTIVE: Vitamin D deficiency is well recognized in selected Middle Eastern countries, but neonatal vitamin D status is not well studied in Jordan and other nearby countries. The aim of this study is to determine the prevalence of vitamin D deficiency in Jordanian newborns and risk factors associated with low levels. METHODS: This is a prospective cohort study of newborn infants who were delivered at the Al Bashir Government Hospital in Amman, Jordan, from January 31, 2010, to January 27, 2011. Heel stick blood samples for 25-hydroxyvitamin D [25(OH)D] levels were obtained within 96 hours of birth. Maternal dress pattern, vitamin supplementation, smoke exposure during pregnancy, mode of delivery, gestational age, and birth weight were documented. RESULTS: Samples were obtained from 3,731 newborns. Median gestational age was 39 weeks, median birth weight was 3.1 kilograms, median maternal age was 27 years, and median newborn 25(OH)D level was 8.6nmol/L. A total of 3,512 newborns (94.1%) in this study were vitamin D deficient (< 50 nmol/L). Lower gestational age, maternal smoke exposure, and birth during winter months were associated with lower infant vitamin D levels, while vitamin D supplementation and time spent outside during pregnancy were associated with higher vitamin D levels. CONCLUSIONS: The prevalence of severely low vitamin D levels in newborn infants in Amman, Jordan, is substantial, even in newborns born during the spring and summer months. Vitamin D supplementation is needed in this population.