Implementing pediatric inpatient asthma pathways.

ObjectivePathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways.MethodsThis was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis.ResultsEighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed.ConclusionsHospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma

Pediatric Spasticity

Children with special health care needs (CSHCN) are increasingly prevalent in US hospitals. The pediatric hospitalist is often the primary provider of inpatient care for these patients. However, exposure to this patient population during training varies from provider to provider. No published educational curricula are specific to the inpatient care of this population. The purpose of this project is to build a multi-modal educational curriculum for providers with the overall goal of improving inpatient care for this at-risk population. This curriculum is primarily composed of a series of topic-specific learning modules. Asynchronous learning modules, utilized appropriately, can augment learning by providing individualized instruction and mastery of fundamentals. This particular resource was created to provide pediatricians with educational materials related to care of the medically complex child with spasticity. This module was distributed to our division. So far, seventeen colleagues have participated in this learning module with favorable results. Comments included good pathophysiology reminders and this was very informative and very well organized. On a 5-point Likert scale evaluation, over 90% of respondents felt that this learning module was A. relevant to my clinical practice, B. will change my clinical practice, C. increase my comfort with teaching this topic to trainees. The average pre-test score was 64% and post-test score was 82% which was statistically significant (p\u3c0.05). This module will be distributed to resident physicians within our institution this academic year. AAMC MedEdPORTAL publication ID 9282. Link to original

Sticking with autologous serum versus stitching with non-absorbable suture conjunctival limbal autograft in primary pterygium surgery

Background: Pterygium is a degenerative ocular surface disorder with wing shaped fibrovascular growth of the subconjunctival tissue onto the cornea. Objectives: The purpose of this study was to compare the surgical outcome of suture less technique with graft suturing technique for conjunctival autograft fixation following pterygium excision. Materials And Methods: This was a prospective interventional case study including 50 eyes with pterygium requiring surgical excision. Operated eyes were divided into two equal groups; Group-1 where conjunctival limbal autograft was placed without using sutures after pterygium excision and Group-2 where conjunctival limbal autograft was fixed by 10-0 ethilon monofilament sutures. Results: Group-1 had shorter duration of surgery (p < 0.001), less postoperative complaints (p < 0.001) and greater patient satisfaction (p < 0.001) than Group-2. Postoperative complications and improvement in visual acuity was same in both groups. Recurrence was not significant in both groups until 6 months of follow up. Conclusions: Patients who underwent suture less autologous graft fixation had comparatively less operative time, less postoperative symptoms and greater satisfaction than graft fixation with sutures post pterygium excision surgery

Optimization-based assisted calibration of traffic simulation models

Use of traffic simulation has increased in recent decades; and this high-fidelity modelling, along with moving vehicle animation, has allowed transportation decisions to be made with better confidence. During this time, traffic engineers have been encouraged to embrace the process of calibration, in which steps are taken to reconcile simulated and field-observed performance. According to international surveys, experts, and conventional wisdom, existing (non-automated) methods of calibration have been difficult or inadequate. There has been extensive research on improved calibration methods, but many of these efforts have not produced the flexibility and practicality required by real-world engineers. With this in mind, a patent-pending (US 61/859,819) architecture for software-assisted calibration was developed to maximize practicality, flexibility, and ease-of-use. This architecture is called SASCO (i.e. Sensitivity Analysis, Self-Calibration, and Optimization). The original optimization method within SASCO was based on "directed brute force" (DBF) searching; performing exhaustive evaluation of alternatives in a discrete, user-defined search space. Simultaneous Perturbation Stochastic Approximation (SPSA) has also gained favor as an efficient method for optimizing computationally expensive, "black-box" traffic simulations, and was also implemented within SASCO. This paper uses synthetic and real-world case studies to assess the qualities of DBF and SPSA, so they can be applied in the right situations. SPSA was found to be the fastest method, which is important when calibrating numerous inputs, but DBF was more reliable. Additionally DBF was better than SPSA for sensitivity analysis, and for calibrating complex inputs. Regardless of which optimization method is selected, the SASCO architecture appears to offer a new and practice-ready level of calibration efficiency. (C) 2015 Elsevier Ltd. All rights reserved.Hale, DK.; Antoniou, C.; Brackstone, M.; Michalaka, D.; Moreno Chou, AT.; Parikh, K. (2015). Optimization-based assisted calibration of traffic simulation models. Transportation Research Part C: Emerging Technologies. 55:100-115. doi:10.1016/j.trc.2015.01.018S1001155

Impact of a National Guideline on Antibiotic Selection for Hospitalized Pneumonia.

BACKGROUND: We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia. METHODS: We assessed inpatient antibiotic prescribing for pneumonia at 28 children\u27s hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not been published based on a projection of a preguideline trend. A similar approach was used to estimate the short-term (6-month) impact of local implementation efforts. The correlations between organizational readiness and the impact of the guideline were estimated by using Pearson\u27s correlation coefficient. RESULTS: Before guideline publication, penicillin prescribing was rare ( CONCLUSIONS: The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals\u27 organizational readiness to change

Is the inflammasome a potential therapeutic target in renal disease?

The inflammasome is a large, multiprotein complex that drives proinflammatory cytokine production in response to infection and tissue injury. Pattern recognition receptors that are either membrane bound or cytoplasmic trigger inflammasome assembly. These receptors sense danger signals including damage-associated molecular patterns and pathogen-associated molecular patterns (DAMPS and PAMPS respectively). The best-characterized inflammasome is the NLRP3 inflammasome. On assembly of the NLRP3 inflammasome, post-translational processing and secretion of pro-inflammatory cytokines IL-1β and IL-18 occurs; in addition, cell death may be mediated via caspase-1. Intrinsic renal cells express components of the inflammasome pathway. This is most prominent in tubular epithelial cells and, to a lesser degree, in glomeruli. Several primary renal diseases and systemic diseases affecting the kidney are associated with NLRP3 inflammasome/IL-1β/IL-18 axis activation. Most of the disorders studied have been acute inflammatory diseases. The disease spectrum includes ureteric obstruction, ischaemia reperfusion injury, glomerulonephritis, sepsis, hypoxia, glycerol-induced renal failure, and crystal nephropathy. In addition to mediating renal disease, the IL-1/ IL-18 axis may also be responsible for development of CKD itself and its related complications, including vascular calcification and sepsis. Experimental models using genetic deletions and/or receptor antagonists/antiserum against the NLRP3 inflammasome pathway have shown decreased severity of disease. As such, the inflammasome is an attractive potential therapeutic target in a variety of renal diseases