Arkansas Children’s Foundation

Importance: Respiratory pathogen testing has been a common deimplementation focus. The COVID-19 pandemic brought new considerations for respiratory testing; recent trends in testing rates are not well understood. Objective: To measure trends in respiratory testing among encounters for acute respiratory infections among children and adolescents (aged <18 years) from 2016 to 2023, assess the association of COVID-19 with these trends, and describe associated cost trends. Design, Setting, and Participants: This retrospective serial cross-sectional study included emergency department (ED) encounters and hospitalizations in US children's hospitals among children and adolescents with a primary acute infectious respiratory illness diagnosis. Data were ascertained from the Pediatric Health Information System database from January 1, 2016, to December 31, 2023. Exposure: Respiratory pathogen testing. Main Outcomes and Measures: The primary outcome was the percentage of encounters with respiratory testing over time. Interrupted time series models were created to assess the association of COVID-19 with testing patterns. The inflation-adjusted standardized unit cost associated with respiratory testing was also examined. Results: There were 5 090 923 eligible encounters among patients who were children or adolescents (mean [SD] age, 3.36 [4.06] years); 55.0% of the patients were male. Among these encounters, 87.5% were ED only, 77.9% involved children younger than 6 years, and 94.5% involved children without complex chronic conditions. Respiratory testing was performed in 37.2% of all encounters. The interrupted time series models demonstrated increasing prepandemic testing rates in both ED-only encounters (slope, 0.26 [95% CI, 0.21-0.30]; P < .001) and hospitalizations (slope, 0.12 [95% CI, 0.07-0.16]; P < .001). Increases in respiratory testing were seen at the onset of the COVID-19 pandemic in both ED-only encounters (level change, 33.78 [95% CI, 31.77-35.79]; P < .001) and hospitalizations (level change, 30.97 [95% CI, 29.21-32.73]; P < .001), associated initially with COVID-19-only testing. Postpandemic testing rates remained elevated relative to prepandemic levels. The percentage of encounters with respiratory testing increased from 13.6% [95% CI, 13.5%-13.7%] in 2016 to a peak of 62.2% [95% CI, 62.1%-62.3%] in 2022. While COVID-19-only testing decreased after 2020, other targeted testing and large-panel (>5 targets) testing increased. The inflation-adjusted standardized unit cost associated with respiratory testing increased from $34.2 [95% CI, $33.9-$34.6] per encounter in 2017 to $128.2 [95% CI, $127.7-$128.6] per encounter in 2022. Conclusions and Relevance: The findings of this cross-sectional study suggest that respiratory testing rates have increased over time, with large increases at the onset of the COVID-19 pandemic that have persisted. Respiratory testing rates and related costs increased significantly, supporting a need for future deimplementation efforts.

Program leaders offer tangible guidance informed by their OPPC development experience. Future work is needed to leverage this advice within institutions to promote resilient and sustainable PPC growth.

Background: Clinicians currently lack an effective means for identifying youth with type 1 diabetes (T1D) who are at risk for experiencing glycemic deterioration between diabetes clinic visits. As a result, their ability to identify youth who may optimally benefit from targeted interventions designed to address rising glycemic levels is limited. Although electronic health records (EHR)-based risk predictions have been used to forecast health outcomes in T1D, no study has investigated the potential for using EHR data to identify youth with T1D who will experience a clinically significant rise in glycated hemoglobin (HbA1c) ≥0.3% (approximately 3 mmol/mol) between diabetes clinic visits. Objective: We aimed to evaluate the feasibility of using routinely collected EHR data to develop a machine learning model to predict 90-day unit-change in HbA1c (in % units) in youth (aged 9-18 y) with T1D. We assessed our model's ability to augment clinical decision-making by identifying a percent change cut point that optimized identification of youth who would experience a clinically significant rise in HbA1c. Methods: From a cohort of 2757 youth with T1D who received care from a network of pediatric diabetes clinics in the Midwestern United States (January 2012-August 2017), we identified 1743 youth with 9643 HbA1c observation windows (ie, 2 HbA1c measurements separated by 70-110 d, approximating the 90-day time interval between routine diabetes clinic visits). We used up to 5 years of youths' longitudinal EHR data to transform 17,466 features (demographics, laboratory results, vital signs, anthropometric measures, medications, diagnosis codes, procedure codes, and free-text data) for model training. We performed 3-fold cross-validation to train random forest regression models to predict 90-day unit-change in HbA1c(%). Results: Across all 3 folds of our cross-validation model, the average root-mean-square error was 0.88 (95% CI 0.85-0.90). Predicted HbA1c(%) strongly correlated with true HbA1c(%) (r=0.79; 95% CI 0.78-0.80). The top 10 features impacting model predictions included postal code, various metrics related to HbA1c, and the frequency of a diagnosis code indicating difficulty with treatment engagement. At a clinically significant percent rise threshold of ≥0.3% (approximately 3 mmol/mol), our model's positive predictive value was 60.3%, indicating a 1.5-fold enrichment (relative to the observed frequency that youth experienced this outcome [3928/9643, 40.7%]). Model sensitivity and positive predictive value improved when thresholds for clinical significance included smaller changes in HbA1c, whereas specificity and negative predictive value improved when thresholds required larger changes in HbA1c. Conclusions: Routinely collected EHR data can be used to create an ML model for predicting unit-change in HbA1c between diabetes clinic visits among youth with T1D. Future work will focus on optimizing model performance and validating the model in additional cohorts and in other diabetes clinics.

Although graft-versus-host disease (GvHD) is an important cause of gastrointestinal (GI) complications after allogeneic hematopoietic stem cell transplantation (HCT), the non-specific symptoms make diagnosis challenging. We described three patients with sickle cell disease who developed inflammatory bowel disease (IBD) like manifestations 4-18 months post-HCT. All patients received peripheral blood stem cell grafts and sirolimus for GvHD prophylaxis. All had chronic diarrhea, and biopsies showed extensive colonic ulceration, non-necrotizing granulomas, with minimal histologic evidence of GvHD. Symptoms resolved promptly with IBD-directed therapy. Our report highlights the importance of considering alternative rare etiologies for GI complications such as IBD after HCT.

BACKGROUND: There is a paucity of information around whether hospital length of stay and readmission rates differ based upon hospital type for adolescents and young adults (AYA) with complex chronic diseases (CCDs). OBJECTIVE: To measure the association between hospital type and readmission rates and index admission LOS among AYA with CCDs. METHODS: We performed a retrospective cross-sectional study of 2017 Healthcare Cost and Utilization Project State Inpatient Databases, including patients 12-25 years old with cystic fibrosis (CF), sickle cell disease (SCD), spina bifida (SB), inflammatory bowel disease (IBD), and diabetes mellitus (DM). Index hospitalizations were categorized by hospital type (pediatric hospitals [PHs], adult hospitals with pediatric services [AHPSs], and adult hospitals without pediatric services [AHs]), CCD, and age group. We compared case-mix adjusted 30-day readmission rates and differences in index admission LOS between hospital types. RESULTS: Adult hospitals without pediatric services exhibited higher readmission rates (25.4%) than AHPS (22.9%) and PH (15.1%). Compared to patients with CF admitted to AH, lower readmission rates were associated with longer LOS at both AHPS (relative ratio [RR]: 1.25, 95% confidence interval [CI]: 1.02-1.55) and PH (RR: 1.59, 95% CI: 1.28-1.97). Patients with DM admitted to AHPS (odds ratio [OR]: 0.75, 95% CI: 0.62-0.91) and PH (OR: 0.47, 95% CI: 0.31-0.71) also demonstrated lower readmission rates than those admitted to AH. CONCLUSIONS: For AYA with CCD, hospital type is associated with differences in readmission rates and LOS. Lower readmission rates at hospitals with pediatric services compared to adult hospitals without pediatric services suggest hospital type has a significant impact on outcomes.

Additional file 7: Table S6. Large blocks of differential CpG methylation identified among the 5 brain region groups.

Abstract Background Master protocols leverage a common trial infrastructure for launching multiple sub-studies. Translational research aims to progress scientific discoveries toward public health impact, which depends on establishing an intervention’s efficacy, effectiveness in real-world conditions, and successful strategies for implementation. While master protocols have been designed to improve the efficiency of clinical trials as sub-studies addressing a particular disease, their application with effectiveness-implementation hybrid studies is yet to be explored. The aim of this study was to develop recommendations for adapting mater protocol methods for effectiveness-implementation research. Methods A method of consultation with translational research networks was undertaken between January and December 2024. Consideration was given to the requirements for service providers to engage in translational research, and how master protocols could support effectiveness-implementation hybrid sub-studies. The underlying rationale for potential adaptations is provided with reference to implementation frameworks, discussion of advantages and disadvantages, and summary recommendations. Results Recommendations are proposed on establishing common trial infrastructure, aims and hypotheses, data collection, control groups, adaptive elements, and eligibility criteria. By leveraging cross-sectoral partnerships, co-producing research and dissemination, and incorporating adaptive elements, master protocols may offer a promising approach for accelerating progress along the translational research pipeline. Conclusions The adaptation of master protocols for hybrid sub-studies could enable evidence-based interventions to be more effectively implemented in routine care settings. The feasibility of master protocols for effectiveness-implementation research is yet to be tested, and further development in this area is needed to trial the proposed methodology.

Additional file 18: Table S17. Overlap between VMRs and SNPs at multiple allele frequencies.

Abstract Background Failure to follow proper guidelines can lead to inappropriate Clostridioides difficile infection (CDI) testing in pediatric patients, resulting in incorrect diagnoses and antibiotic overuse. The Infectious Diseases Society of America and Society for Healthcare Epidemiology of America recommend a 2-step testing algorithm incorporating restrictions based on age, exposure, and underlying conditions. With these recommendations, a CDI bundle was implemented to reduce unnecessary testing in pediatric patients. Outcomes were measured via National Healthcare Safety Network (NHSN) LabID reporting. Methods An interdisciplinary team reviewed the CDI ordering process in a 24-bed community pediatric hospital with an Emergency Department (ED). Previous testing only used toxigenic C. difficile PCR without order restrictions. In September 2021, a CDI bundle was implemented, including a 2-step algorithm (toxigenic C. difficile PCR, toxin A/B immunoassay), a physician guidance pathway, and Epic order restrictions (Table 1). Outcomes were measured by examining NHSN LabID data before and after bundle implementation. Inpatient and ED data were reported under the appropriate NHSN patient safety module. CDI rates were calculated by the number of infections/1000 inpatient days and number of infections/1000 ED encounters. There was a 12-month pre-implementation period (August 2020-July 2021), a 3-month implementation period (August 2021-October 2021), and a 12-month post-implementation period (November 2021-October 2022). Results A statistically significant decrease in the CDI incidence was seen after CDI bundle implementation (P&amp;lt; 0.05 for both inpatient and ED using test of proportions). The average CDI incidence decreased from 2.24 to zero infections/1000 inpatient days (Figure 1) and from 0.58 to 0.02 infections/1000 ED encounters (Figure 2). Conclusion CDI diagnostic bundle implementation effectively decreased the number of abnormal CDI test results, and positively impacted data reported to NHSN. Further analysis is warranted to delineate the impact of CDI bundle implementation on patient treatment, antimicrobial stewardship, and healthcare costs. Disclosures Jessica Snowden, MD, MHPTT, Pfizer: Advisor/Consultant

Additional file 13: Table S12. CH DMRs identified among neuronal samples isolated from the basal ganglia tissues and between the two hippocampus tissue groups.

Supplementary Material 2.

Additional file 5: Table S4. CpG DMRs identified among neuronal samples isolated from all 8 brain regions.

Additional file 14: Table S13. Lists of VMRs identified in each tissue.

Additional file 9: Table S8. GREAT analysis of basal ganglia CpG DMRs and the top 2000 Hippocampal CpG DMRs.

Introduction: Effective liver retraction is a crucial step in laparoscopic hiatal surgery, providing optimal exposure of the esophageal hiatus and esophagogastric junction. Various techniques have been developed to achieve adequate visualization, but many are associated with potential complications, including significant postoperative elevations in liver enzymes and more severe hepatic injuries such as lacerations, bleeding, and even liver necrosis. The “tuck-away liver retraction” technique, which involves tucking the left lobe of the liver through a window in the falciform ligament, has been described as a safe alternative in single-port laparoscopic surgery. However, its application in standard laparoscopic procedures has not been extensively studied. Methods: A retrospective review was conducted on 82 pediatric patients who underwent laparoscopic surgery for hiatal pathologies between January 2018 and December 2023. The “tuck-away” liver retraction technique was employed in 9 cases where traditional retraction methods were insufficient due to large liver size or limited working space. Data on patient demographics, operative time, intraoperative complications, and postoperative liver enzyme levels were collected and analyzed.Results: The “tuck-away” liver retraction technique was successfully performed in 9 out of 10 cases (90%). The mean operative time for the liver retraction procedure was 18±3.8 minutes. Minor liver abrasions were observed in 3 cases (33.3%), managed effectively with cauterization. No major liver injuries, subcapsular hematomas, or significant postoperative liver enzyme elevations were reported, demonstrating the technique’s safety and feasibility.Conclusion: The “tuck-away” liver retraction technique is a viable and safe alternative for liver retraction in laparoscopic hiatal surgery, particularly in challenging cases involving large livers or limited working space. Although technically demanding, this method offers excellent exposure with minimal risk of liver injury. Further studies with larger sample sizes are recommended to validate these findings and refine the technique’s application.

Additional file 16: Table S15. Links and references to summary statistics for traits used in SLDSR analyses.

Additional file 10: Table S9. CpG DMRs identified among neuronal samples isolated from the two hippocampus tissue groups.

Additional file 4: Table S3. Samples failing genotype quality check.

Additional file 12: Table S11. CH DMRs identified among the 5 brain regions groups.

Additional file 17: Table S16. Results from SLDSR analyses.