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Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone.Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting.943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics.Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment.

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Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP).We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP.We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP.The exposure was the receipt of antibiotics in the emergency department (ED).Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses.Among 523 children, 66% were5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.

Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP).We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes.This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals.We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes.We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs.There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.

Objective Although interactive data visualizations are increasingly popular for health communication, it remains to be seen what design features improve psychological and behavioral targets. This study experimentally tested how interactivity and descriptive titles may influence perceived susceptibility to the flu, intention to vaccinate, and information recall, particularly among older adults. Materials and Methods We created data visualization dashboards on flu vaccinations, tested in a 2 (explanatory text vs none) × 3 (interactive + tailored, static + tailored, static + nontailored) + questionnaire-only control randomized between-participant online experiment (N = 1378). Results The flu dashboards significantly increased perceived susceptibility to the flu compared to the control: static+nontailored dashboard, b = 0.14, P = .049; static-tailored, b = 0.16, P = .028; and interactive+tailored, b = 0.15, P = .039. Interactive dashboards potentially decreased recall particularly among the elderly (moderation by age: b = −0.03, P = .073). The benefits of descriptive text on recall were larger among the elderly (interaction effects: b = 0.03, P = .025). Discussion Interactive dashboards with complex statistics and limited textual information are widely used in health and public health but may be suboptimal for older individuals. We experimentally showed that adding explanatory text on visualizations can increase information recall particularly for older populations. Conclusion We did not find evidence to support the effectiveness of interactivity in data visualizations on flu vaccination intentions or on information recall. Future research should examine what types of explanatory text can best support improved health outcomes and intentions in other contexts. Practitioners should consider whether interactivity is optimal in data visualization dashboards for their populations.

B cells, also known as B lymphocytes or lymphoid lineage cells, are a historically understudied cell population with regard to brain-related injuries and diseases. However, an increasing number of publications have begun to elucidate the different phenotypes and roles B cells can undertake during central nervous system (CNS) pathology, including following ischemic and hemorrhagic stroke. B cell phenotype is intrinsically linked to function following stroke, as they may be beneficial or detrimental depending on the subset, timing, and microenvironment. Factors such as age, sex, and presence of co-morbidity also influence the behavior of post-stroke B cells. The following review will briefly describe B cells from origination to senescence, explore B cell function by integrating decades of stroke research, differentiate between the known B cell subtypes and their respective activity, discuss some of the physiological influences on B cells as well as the influence of B cells on certain physiological functions, and highlight the differences between B cells in healthy and disease states with particular emphasis in the context of ischemic stroke.

OBJECTIVE To characterize the outcomes of children with community acquired pneumonia (CAP) across 41 United States hospitals and evaluate factors associated with potentially unnecessary admissions. METHODS We performed a cross-sectional study of patients with CAP from 41 United States pediatric hospitals and evaluated clinical outcomes using a composite ordinal severity outcome: mild-discharged (discharged from the emergency department), mild-admitted (hospitalized without other interventions), moderate (provision of intravenous fluids, supplemental oxygen, broadening of antibiotics, complicated pneumonia, and presumed sepsis) or severe (ICU, positive-pressure ventilation, vasoactive infusion, chest drainage, extracorporeal membrane oxygenation, severe sepsis, or death). Our primary outcome was potentially unnecessary admissions (ie, mild-admitted). Among mild-discharged and mild-admitted patients, we constructed a generalized linear mixed model for mild-admitted severity and assessed the role of fixed (demographics and clinical testing) and random effects (institution) on this outcome. RESULTS Of 125 180 children, 68.3% were classified as mild-discharged, 6.6% as mild-admitted, 20.6% as moderate and 4.5% as severe. Among admitted patients (n = 39 692), 8321 (21%) were in the mild-admitted group, with substantial variability in this group across hospitals (median 19.1%, interquartile range 12.8%–28.4%). In generalized linear mixed models comparing mild-admitted and mild-discharge severity groups, hospital had the greatest contribution to model variability compared to all other variables. CONCLUSIONS One in 5 hospitalized children with CAP do not receive significant interventions. Among patients with mild disease, institutional variation is the most important contributor to predict potentially unnecessary admissions. Improved prognostic tools are needed to reduce potentially unnecessary hospitalization of children with CAP.

BACKGROUND Antibiotics are frequently used for community-acquired pneumonia (CAP), although viral etiologies predominate. We sought to determine factors associated with antibiotic use among children hospitalized with suspected CAP. METHODS We conducted a prospective cohort study of children who presented to the emergency department (ED) and were hospitalized for suspected CAP. We estimated risk factors associated with receipt of ≥1 dose of inpatient antibiotics and a full treatment course using multivariable Poisson regression with an interaction term between chest radiograph (CXR) findings and ED antibiotic use. We performed a subgroup analysis of children with nonradiographic CAP. RESULTS Among 477 children, 60% received inpatient antibiotics and 53% received a full course. Factors associated with inpatient antibiotics included antibiotic receipt in the ED (relative risk 4.33 [95% confidence interval, 2.63–7.13]), fever (1.66 [1.22–2.27]), and use of supplemental oxygen (1.29 [1.11–1.50]). Children with radiographic CAP and equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Factors associated with a full course were similar. Among patients with nonradiographic CAP, 29% received inpatient antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics. CONCLUSIONS Inpatient antibiotic utilization was associated with ED antibiotic decisions, CXR findings, and clinical factors. Nearly one-third of children with nonradiographic CAP received antibiotics, highlighting the need to reduce likely overuse. Antibiotic decisions in the ED were strongly associated with decisions in the inpatient setting, representing a modifiable target for future interventions.

BACKGROUND Several prediction models have been reported to identify patients with radiographic pneumonia, but none have been validated or broadly implemented into practice. We evaluated 5 prediction models for radiographic pneumonia in children. METHODS We evaluated 5 previously published prediction models for radiographic pneumonia (Neuman, Oostenbrink, Lynch, Mahabee-Gittens, and Lipsett) using data from a single-center prospective study of patients 3 months to 18 years with signs of lower respiratory tract infection. Our outcome was radiographic pneumonia. We compared each model’s area under the receiver operating characteristic curve (AUROC) and evaluated their diagnostic accuracy at statistically-derived cutpoints. RESULTS Radiographic pneumonia was identified in 253 (22.2%) of 1142 patients. When using model coefficients derived from the study dataset, AUROC ranged from 0.58 (95% confidence interval, 0.52–0.64) to 0.79 (95% confidence interval, 0.75–0.82). When using coefficients derived from original study models, 2 studies demonstrated an AUROC >0.70 (Neuman and Lipsett); this increased to 3 after deriving regression coefficients from the study cohort (Neuman, Lipsett, and Oostenbrink). Two models required historical and clinical data (Neuman and Lipsett), and the third additionally required C-reactive protein (Oostenbrink). At a statistically derived cutpoint of predicted risk from each model, sensitivity ranged from 51.2% to 70.4%, specificity 49.9% to 87.5%, positive predictive value 16.1% to 54.4%, and negative predictive value 83.9% to 90.7%. CONCLUSIONS Prediction models for radiographic pneumonia had varying performance. The 3 models with higher performance may facilitate clinical management by predicting the risk of radiographic pneumonia among children with lower respiratory tract infection.

BACKGROUND/OBJECTIVE: Pediatric patients hospitalized with bacterial infections often receive intravenous (IV) antibiotics. Early transition to enteral antibiotics can reduce hospital duration, cost, and complications. We aimed to identify opportunities to transition from IV to enteral antibiotics, describe variation of transition among hospitals, and evaluate feasibility of novel stewardship metrics. METHODS: This multisite retrospective cohort study used the Pediatric Health Information System to identify pediatric patients hospitalized with pneumonia, neck infection, orbital infection, urinary tract infection (UTI), osteomyelitis, septic arthritis, or skin and soft tissue infection (SSTI) between 2017 and 2018. Opportunity days were defined as days on which patients received both IV antibiotics and enteral medications, suggesting enteral tolerance. Percent opportunity was defined as opportunity days divided by days on any antibiotics. Both outcomes excluded IV antibiotics that have no alternative oral formulation. We evaluated outcomes per infection and antibiotic and assessed across-hospital variation. RESULTS: We identified 88,522 aggregate opportunity days in 100,103 hospitalizations. On 57% of the antibiotic days, there was an opportunity to switch patients to enteral therapy, with greatest opportunity days in SSTI, neck infection, and pneumonia encounters, and with clindamycin, ceftriaxone, and ampicillin-sulbactam. Percent opportunity varied by infection (73% in septic arthritis to 40% in pneumonia). There was significant across-hospital variation in percent opportunity for all infections. CONCLUSION: This multicenter study demonstrated the potential opportunity to transition from IV to enteral therapy in over half of antibiotic days. Opportunity varied by infection, antibiotic, and hospital. Across-hospital variation demonstrated likely missed opportunities for earlier transition and the need to define optimal transition times. Stewardship efforts promoting earlier transition for highly bioavailable antibiotics could reduce healthcare utilization and promote high-value care. We identified feasible stewardship metrics.

The specialty coffee industry emphasizes the importance of personal relationships that span disparate levels of the supply chain and production models that focus on the wellbeing of coffee ...

Gaza City, with a population of over half a million residents, is the largest urban center and de-facto capital of the Gaza Strip, which itself has a total population of over 1.8 million. As of 2018, it is estimated that at least 1.3 million of the residents of the Gaza Strip are Palestinian refugees from other areas in historic Palestine, having fled to Gaza after the creation of the State of Israel in 1948. These refugee communities originally come from the many historic rural areas that surrounded the Gaza Strip, smaller towns and cities along the Mediterranean coast, as well as areas further afield such as Jaffa, 69 km north of Gaza on the coast, and Bir il-Sab‘, the largest city in the Nagab desert region (see Figure 1). Linguistically, many of these refugee communities are of Palestinian Arabic dialect backgrounds, although varieties of Arabic spoken in the Nagab are classified as originating in the Hijaz area of what is today Saudi Arabia (see Shahin 2007 on Palestinian Arabic and Henkin 2010 on Nagab Arabic).

In recent years, studies have shown that low-dose computed tomography (LDCT) is a safe and effective way to screen high-risk adults for lung cancer. Despite this, uptake remains low, especially in limited-resource settings. The American Cancer Society (ACS) partnered with two federally qualified health centers and accredited screening facilities on a 2 year pilot project to implement an LDCT screening program. Both sites attempted to develop a referral program and care coordination practices to move patients through the screening continuum and identify critical facilitators and barriers to implementation. Evaluators conducted key informant interviews (N = 46) with clinical and administrative staff, as well as regional ACS staff during annual site visits. The Consolidated Framework for Implementation Research guided our analysis of factors associated with effective implementation and improved screening outcomes. One study site established a sustainable lung screening program, while the other struggled to overcome significant implementation barriers. Increased time spent with patients, disruption to normal workflows, and Medicaid reimbursement policies presented challenges at both sites. Supportive, engaged leaders and knowledgeable champions who provided clear implementation guidance improved staff engagement and were able to train, guide, and motivate staff throughout the intervention. A slow, stepwise implementation process allowed one site’s project champions to pilot test new processes and resolve issues before scaling up. This pilot study provides critical insights into the necessary resources and steps for successful lung cancer screening program implementation in underserved settings. Future efforts can build upon these findings and identify and address possible facilitators and barriers to screening program implementation., Implementing a lung cancer screening program was facilitated by leadership support, dedicated project champions, technology solutions, and a slow, stepwise implementation process.

Novel methyl and methoxy ring-disubstituted 2-methoxyethyl phenylcyanoacrylates, RPhCH=C(CN)CO2CH2CH2OCH3 (where R is 2,3-dimethyl, 2,4-dimethyl, 2,5-dimethyl, 2,6-dimethyl, 3,4-dimethyl, 3,5-dimethyl, 2,3-dimethoxy, 2,4-dimethoxy, 2,5-dimethoxy, 2,6-dimethoxy, 3,4-dimethoxy, 3,5-dimethoxy) were prepared and copolymerized with styrene. The acrylates were synthesized by the piperidine catalyzed Knoevenagel condensation of ring-substituted benzaldehydes and 2-methoxyethyl cyanoacetate, and characterized by CHN analysis, IR, 1H and 13C NMR. All the acrylates were copolymerized with styrene in solution with radical initiation (ABCN) at 70C. The compositions of the copolymers were calculated from nitrogen analysis.

Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures.(1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals.Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care.Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs.We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization.Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

BACKGROUND: Acute otitis media (AOM) is a common pediatric condition known to contribute to excessive antibiotic use in the outpatient setting. Treatment of AOM in the inpatient setting has not been described. The objective was to describe the clinical features and inpatient management of AOM to harness this entity to teach learners about judicious antibiotic prescribing in all settings. METHODS: This is a single-center retrospective cohort study of inpatients treated for AOM from January 2015 to December 2018. Patients were included if they had an antibiotic ordered and either a provider-selected order indication of otitis media or an International Classification of Diseases, 10th Revision billing code of AOM. A chart review was performed to identify primary diagnoses, examination features, and treatment, including excess days of therapy. RESULTS: We included 840 hospitalized patients treated for AOM in this study. At least 71% of patients had a concurrent viral respiratory illness. Examinations were frequently discordant (34%), and 47% lacked documentation of a physical examination finding of a bulging tympanic membrane, contributing to 3417 potential excess days of therapy. Of the total patients treated for AOM, 40% were given excess duration of therapy. The vast majority (97%) of patients who qualified for a wait-and-watch approach were treated. CONCLUSIONS: AOM is not being rigorously diagnosed or treated in a guideline-adherent manner in the inpatient setting. This is a lost opportunity for teaching antibiotic stewardship. Interventions, such as promoting the wait-and-watch approach and deferring treatment decisions to inpatient providers, could help promote the judicious use of antibiotics.

Changes in phytoplankton community composition and structure can have broad-scale ecosystem effects; however, drivers of species diversity in planktonic systems are not well understood. In lakes, a common but not thoroughly tested assumption is that shallow, nearshore waters are much more diverse and productive, and contribute considerably more material and energy to pelagic food webs than deeper waters farther offshore. Lake Superior is a large, cold, oligotrophic freshwater system which can provide insight into community organization under oligotrophic conditions. We used epilimnion and deep chlorophyll layer phytoplankton data from a lake-wide sampling program conducted in 2011 and 2016 to test whether assemblage composition, total algal biovolume, cell concentrations, diversity, and richness vary with depth. Although lake depth was an important factor in structuring assemblage composition, there were no clear nearshore-offshore gradients in cell density or biovolume despite the exposure of nearshore areas to higher concentrations of watershed-derived nutrients. Shannon diversity increased slightly with increasing depth, whereas richness was uncorrelated. Understanding of the nearshore-offshore patterns in phytoplankton community characteristics in the Great Lakes has implications for designing monitoring strategies and for considering how further changes in climate and nutrient deposition would affect the base of the food web.

Background A moderate to severe (M/S) influenza clinical endpoint has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. The objective of the study was to evaluate the M/S measure against clinically relevant outcomes including hospitalization, emergency room visits, antimicrobial use, and child/parental absenteeism. Methods We conducted a prospective observational study of children aged 6 months–8 years at the Children’s Hospital Colorado emergency department (ED) and urgent care site during 2016–2017 and 2017–2018. Children with influenza-like illness (ILI) underwent influenza testing by polymerase chain reaction (PCR); children who tested positive and a subset of matched test-negative controls underwent follow-up at 2 weeks. The primary outcome was the proportion of children who were hospitalized. Secondary outcomes included recurrent ED visits, antimicrobial use, hospital charges, and child/parental absenteeism within 14 days. Results Among 1478 children enrolled with ILI, 411 (28%) tested positive for influenza by PCR. Of children with influenza illness, 313 (76%) met the M/S definition. Children with M/S influenza were younger (3.8 years vs 4.8 years), infected with influenza A (59% vs 44%), and more frequently hospitalized (unadjusted risk difference [RD], 6.3%; 95% confidence interval [CI], 2.1–10.4; P = .03) and treated with antibiotics (unadjusted RD, 13.3%; 95% CI, 4.3–22.4; P < .01) compared to those with mild disease. Conclusions Children with M/S influenza have a higher risk of hospitalization and antibiotic use compared with mild disease. This proposed definition may be a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children. Clinical Trials Registration NCT02979626.

OBJECTIVES: Procalcitonin (PCT) is a relatively novel biomarker that may be superior to C-reactive protein (CRP) in identifying bacterial infection. PCT use in pediatric hospitals is relatively unknown. We aimed to evaluate PCT and CRP use, describe PCT testing variability across children’s hospitals, and compare temporal rates of PCT and CRP testing for patients admitted with pneumonia, sepsis, or fever in young infants. METHODS: In this multicenter cohort study, we identified children ≤18 years old hospitalized from 2014–2018 with pneumonia, sepsis, or fever in infants RESULTS: From 2017–2018, PCT testing occurred in 3988 of 34c231 (12%) hospitalizations. Febrile infants had the highest PCT testing proportion (18%), followed by sepsis (15%) and pneumonia (9%). There was across-hospital variability in PCT testing, particularly for febrile infants. Over time, the odds of PCT testing increased at a significantly greater rate than that of CRP. CONCLUSIONS: Despite limited guideline recommendations for PCT testing during the study period, PCT use increased over time with across-hospital variability. For pneumonia and sepsis, given the importance of high-value care, we need to understand the impact of PCT on patient outcomes. With recent guidelines recommending PCT in the evaluation of febrile infants, we identified baseline testing behaviors for future studies on guideline impact.

OBJECTIVESResearchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24–36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children’s hospitals.METHODSWe conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions.RESULTSWe identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children’s hospitals, range 33.5–77.9 hours in 2016 and 30.4–100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (−23.9 to +26.7 hours; median change −1.8 hours, interquartile range: −5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70).CONCLUSIONSThe LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children’s hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.

BACKGROUND The purpose of this study was to compare the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) preparation in eradicating Cutibacterium acnes at the deltopectoral interval measured by positive, quantitative culture findings. METHODS Adult male volunteers were randomized to 1 of 3 treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. In the BLT group, a single 23-minute treatment was administered at an estimated irradiance of 40 mW/cm2 (radiant exposure, 55.2 J/cm2). In the BPO-BLT group, volunteers received both treatments as described earlier. After treatment with either BPO, BLT, or both, a single swab culture was taken from the treatment shoulder. Next, control and treatment shoulders were prepared with CHX, and cultures were taken from each shoulder. Cultures were sent for anaerobic quantitative growth analysis with both polymerase chain reaction and Sanger sequencing confirmation of presumptive C acnes colonies. RESULTS This study enrolled 60 male volunteers, 20 per group, with no loss to follow-up. After treatment but prior to CHX administration, all culture samples in the BPO group and BLT group grew C acnes. Prior to CHX, 16 samples (80%) in the BPO-BLT group grew C acnes. On quantitative analysis, the BPO group and BPO-BLT group had significantly less growth of C acnes compared with the BLT group after treatment but prior to CHX (P < .05 for each). Following CHX administration, the BPO and BPO-BLT groups had significantly fewer positive culture findings (odds ratios of 0.03 and 0.29, respectively) and less quantity of growth compared with their control arms (P < .05). This was not seen in the BLT group. For quantitative between-group analysis, no significant synergistic effects were seen with BPO-BLT compared with BPO alone (P = .688). There was no difference in side effects between groups. CONCLUSION The combination of topical BPO and CHX was effective at eliminating C acnes in most cases. BLT alone did not demonstrate effective antimicrobial properties against C acnes at the radiant exposure administered in this study. Combining BPO and BLT did not lead to significant synergistic antimicrobial effects. Both BPO and BLT are safe with few, transient side effects reported. More work is needed to determine whether BLT at higher radiant exposures or serial treatment results in bactericidal effects against C acnes in vivo.

BACKGROUND AND OBJECTIVES:Previous pediatric studies have revealed substantial variation in laboratory testing for specific conditions, but clinical outcomes associated with high- versus low-frequency testing are unclear. We hypothesized that hospitals with high- versus low-testing frequency would have worse clinical outcomes.METHODS:We conducted a multicenter retrospective cohort study of patients 0 to 18 years old with low-acuity hospitalizations in the years 2018–2019 for 1 of 10 common All Patient Refined Diagnosis Related Groups. We identified hospitals with high-, moderate-, and low-frequency testing for 3 common groups of laboratory tests: complete blood cell count, basic chemistry studies, and inflammatory markers. Outcomes included length of stay, 7- and 30-day emergency department revisit and readmission rates, and hospital costs, comparing hospitals with high- versus low-frequency testing.RESULTS:We identified 132 391 study encounters across 44 hospitals. Laboratory testing frequency varied by hospital and condition. We identified hospitals with high- (13), moderate- (20), and low-frequency (11) laboratory testing. When we compared hospitals with high- versus low-frequency testing, there were no differences in adjusted hospital costs (rate ratio 0.89; 95% confidence interval 0.71–1.12), length of stay (rate ratio 0.98; 95% confidence interval 0.91–1.06), 7-day (odds ratio 0.99; 95% confidence interval 0.81–1.21) or 30-day (odds ratio 1.01; 95% confidence interval 0.82–1.25) emergency department revisit rates, or 7-day (odds ratio 0.84; 95% confidence interval 0.65–1.25) or 30-day (odds ratio 0.91; 95% confidence interval 0.76–1.09) readmission rates.CONCLUSIONS:In a multicenter study of children hospitalized for common low-acuity conditions, laboratory testing frequency varied widely across hospitals, without substantial differences in outcomes. Our results suggest opportunities to reduce laboratory overuse across conditions and children’s hospitals.

The notion that Lake Superior proper is inhospitable to dreissenid mussel survival has been challenged by recent finds on shipwrecks and rocky reefs in the Apostle Islands region. Motivated by concerns surrounding these finds, we conducted an intensive sampling campaign of Apostle Islands waters in 2017 to understand Dreissena prevalence and distribution. The 100-site effort combined random and targeted sites and collected zooplankton, benthos, video, environmental DNA, and supporting water quality data. We did not find settled Dreissena in any video footage or benthos samples, and quantitative PCR applied to eDNA samples was negative for Dreissena. Dreissena veligers were found in almost half the zooplankton samples but at orders of magnitude lower densities than reported from other Laurentian Great Lakes. Veligers were most prevalent around the western islands and associated with shallower depths and slightly higher phosphorus and chlorophyll, but did not spatially match known (still very localized) settled Dreissena colonies. This is the first study to conduct veliger-targeted sampling in western Lake Superior and the first to report consistent detection of veligers there. We speculate that these Apostle Islands veligers are not a new locally-spawned component of the zooplankton community, but instead are transported from an established population in the St. Louis River estuary (~100 km away) by longshore currents; i.e., low-density propagule pressure that may have been present for years. Small-mesh zooplankton data collected along a gradient from the Apostle Islands to the St. Louis River estuary and enumerated with thorough veliger searching would help elucidate these alternatives.

OBJECTIVES: Evidence supports using dexamethasone for mild-to-moderate asthma exacerbations in the emergency department, but the effectiveness of dexamethasone versus prednisone for asthmatic patients who are hospitalized is unclear. Our aim was to compare outcomes for inpatients before and after our emergency department’s adoption of dexamethasone for the treatment of acute asthma exacerbations. METHODS: In this single-center retrospective cohort study, we employed interrupted time series analyses to control for secular trends while evaluating our outcomes of length of stay, total inflation-adjusted hospital charges, and ICU transfer rates for patients admitted with asthma. RESULTS: Data were analyzed over 36 months (January 2014–April 2017) and included 1015 subjects (606 in the preprotocol change [pre-PC] group and 409 in the postprotocol change [post-PC] group). In the pre-PC group, prednisone only was used in 96% of subjects. In the post-PC group, prednisone only was used in 7% of subjects, dexamethasone in 65% of subjects, and a combination of the 2 steroids in 28% of subjects. Controlling for other variables in the interrupted time series model, we found no significant immediate differences between the pre-PC and post-PC periods for the outcomes of length of stay (P = .68), total charges (P = .66), and ICU transfers (P = .98). The rate of ICU transfers was stable pre-PC and increased by 10% (95% confidence interval: 2%–19%) per month (odds ratio = 1.10; 95% confidence interval: 1.02–1.19; P = .02) in the post-PC period. CONCLUSIONS: After dexamethasone replaced prednisone as the most commonly prescribed steroid type for inpatients with asthma at our institution, we found no immediate changes in outcomes for asthmatic patients who were hospitalized but an upward trend in ICU transfers.

Background Breast cancer screening utilization steeply dropped at the start of the coronavirus disease 2019 (COVID-19) pandemic. However, the effects on breast cancer screening in lower income populations are unknown. This study examined changes in breast cancer screening rates (BCSRs) during the pandemic among 32 community health centers (CHCs) that provided health care to lower income populations. Methods Secondary data from 32 CHCs participating in an American Cancer Society grant program to increase breast cancer screening services were used. BCSRs were defined as the percentage of women aged 50 to 74 years who had a medical visit in the past 12 months (142,207 in 2018, 142,003 in 2019, and 150,630 in 2020) and received a screening mammogram within the last 27 months. BCSRs in July 2020, July 2019, and June 2018 were compared with screening rate ratios (SRRs) and corresponding 95% confidence intervals (CIs). Results BCSRs significantly rose by 18% between 2018 and 2019 (from 45.8% to 53.9%; SRR, 1.18; 95% CI, 1.17-1.18) and then declined by 8% between 2019 and 2020 (from 53.9% to 49.6%; SRR, 0.92; 95% CI, 0.92-0.93). If the 2018-2019 BCSR trends had continued through 2020, 63.3% of women would have been screened in 2020 in contrast to the 49.6% who were; this potentially translated into 47,517 fewer mammograms and 242 missed breast cancer diagnoses in this population. Conclusions In this study of 32 CHCs, BCSRs declined by 8% from July 2019 to 2020, and this reversed an 18% improvement between July 2018 and 2019. Declining BCSRs among CHCs during the COVID-19 pandemic call for policies to support and resources to identify women in need of screening.

OBJECTIVES: Many hospitals have transitioned from conventional stool diagnostics to rapid multiplex polymerase chain reaction gastrointestinal panels (GIP). The clinical impact of this testing has not been evaluated in children. In this study, we compare use, results, and patient outcomes between conventional diagnostics and GIP testing. METHODS: This is a multicenter cross-sectional study of children who underwent stool testing from 2013 to 2017. We used bivariate analyses to compare test use, results, and patient outcomes, including length of stay (LOS), ancillary testing, and hospital charges, between the GIP era (24 months after GIP introduction) and conventional diagnostic era (historic control, 24 months before). RESULTS: There were 12 222 tests performed in 8720 encounters. In the GIP era, there was a 21% increase in the proportion of children who underwent stool testing, with a statistically higher percentage of positive results (40% vs 11%), decreased time to result (4 vs 31 hours), and decreased time to treatment (11 vs 35 hours). Although there was a decrease in LOS by 2 days among those who received treatment of a bacterial and/or parasitic pathogen (5.1 vs 3.1; P < .001), this represented only 3% of tested children. In the overall population, there was no statistical difference in LOS, ancillary testing, or charges. CONCLUSIONS: The GIP led to increased pathogen detection and faster results. This translated into improved outcomes for only a small subset of patients, suggesting that unrestricted GIP use leads to low-value care. Similar to other novel rapid diagnostic panels, there is a critical need for diagnostic stewardship to optimize GIP testing.

Background Asthma and chronic obstructive pulmonary disease (COPD) are the most prevalent respiratory diseases, yet the lack of accessible standardised diagnostics in primary care often lead to erroneous or delayed diagnosis. In-community standardised respiratory diagnostic hubs (RDH) may improve patient access and diagnosis quality of asthma and COPD. Aim To evaluate the effectiveness of a RDH in primary care in establishing diagnosis in patients with suspected asthma and COPD. Methods A pilot multidisciplinary RDH was set up in inner city cosmopolitan Birmingham, to provide diagnostic services to the local population. Referred patients with suspected asthma, COPD had structured review inclusive of lung function and fraction exhaled nitric oxide ‘FeNO’ measurement. The interim diagnostic outcomes of this RDH are presented. Results Of 100 referred cases, 61 were for suspected asthma and 39 for suspected COPD. In the suspected asthma group, there were 12 (20%) cases on the asthma quality outcome framework ‘QOF’ register. Following RDH assessment, asthma was confirmed in 3/12(25%), excluded in 8/12 (67%), and remained suspected in 1/12 (8%), whilst in the 49/61 (80%) suspected asthma not on QOF register, asthma was confirmed in 18/49 (37%), remained suspected in 7/49 (14%) and an alternative diagnosis was established in 24/49 cases (49%). In the overall suspected asthma group, asthma was confirmed in 21/61 (34%) of cases, excluded in 32/61 (53%) and remained suspected in 8/61 (13%), demonstrating a diagnostic outcome in 53/61 (87%) cases. In suspected COPD, only 4 patients were on the COPD QOF register but the diagnosis was excluded in 3 of these cases following RDH assessment. In not-QOF registered suspected COPD, 11/35 (31%) had COPD confirmation, 22/35 (63%) had an alternative diagnosis and 2/35 (6%) remained suspected for COPD. RDH provided a diagnostic outcome in 37/39 (95%). Conclusion This pilot primary care RDH achieved a diagnostic outcome in the vast majority of referred cases, with asthma and COPD diagnoses excluded in over half of all referred cases. Additionally, asthma and COPD diagnoses were excluded in more than half of cases on the QOF register, prompting the need for applying this model of service at wider scale in the NHS.

Background Whilst the largest majority of care of patients suffering from asthma and chronic obstructive pulmonary disease (COPD) resides in primary care, lack of access to essential diagnostics often leads to diagnosis without objective confirmation or on referrals to local hospitals. Creation of in-community diagnostic hubs has been advocated to provide early correct diagnosis, prevent unnecessary referrals to secondary care, or identify and refer early those who require specialist care. Aim To evaluate the clinical characteristics of patients reviewed at a pilot primary care Respiratory Diagnostic Hub (RDH) that would inform referral criteria. Methods We have set up a pilot RDH in primary care in cosmopolitan inner city Birmingham as a collaborative between primary and secondary care, commenced in July 2019. The RDH formed of a multidisciplinary team of clinicians, nurses and physiologists, provided lung function testing and applied national guidelines for asthma and COPD diagnosis. Demographics and the key interim parameter indices are presented. Results A total of 100 patients were reviewed (51 females, mean age 48.5 years range 16–82, Caucasian=46, Asian=38, African=9, others=7). The mean FEV12.49±0.81L: FEV1/FVC ratio 74.5±12.8, mean blood eosinophils 0.3±0.23 × 109/L, mean FeNO 33±43ppb. There were more referrals for suspected asthma (61%) than COPD (39%). Asthma was confirmed in 21/61 (34%), remained suspected in 8/61 (13%) and 32 (53%) had an alternative diagnoses (intractable cough, COPD, gastro-oesophageal reflux, others). In the confirmed asthma, FEV1% predicted was 80% in 11/21(53%). The asthma control test (ACT) was 20 in 3/21 (14%). COPD was confirmed in 12/39 (31%), remained suspected in 2/39(5%), and alternative diagnosis (included bronchitis, asthma, GORD, restrictive lung disease, no diagnosis) in 25/39 (64%). In confirmed COPD group, FEV1% predicted was 80% in 7/12 (58%). The COPD assessment test ‘CAT’ scores distribution were 20 in 5/11(46%). Conclusion In this pilot, significant proportion of referred cases had alternative diagnoses to asthma or COPD, with observed discordance between symptoms scores and lung function impairment in confirmed cases.

Novel trisubstituted ethylenes, methyl and methoxy ring-disubstituted 2-methoxyethyl phenylcyanoacrylates, RPhCH=C(CN)CO2CH2CH2OCH3 (where R is 2,3-dimethyl, 2,4-dimethyl, 2,5-dimethyl, 2,6-dimethyl, 3,4-dimethyl, 3,5-dimethyl, 2,3-dimethoxy, 2,4-dimethoxy, 2,5-dimethoxy, 2,6-dimethoxy, 3,4-dimethoxy, 3,5-dimethoxy) were prepared and copolymerized with styrene. The ethylenes were synthesized by the piperidine catalyzed Knoevenagel condensation of ring-substituted benzaldehydes and 2-methoxyethyl cyanoacetate, and characterized by CHN analysis, IR, 1H and 13C NMR. All the ethylenes were copolymerized with styrene in solution with radical initiation (ABCN) at 70°C. The compositions of the copolymers were calculated from nitrogen analysis.

Using low-dose computed tomography (LDCT) to screen for lung cancer is associated with improved outcomes among eligible current and former smokers (ie, aged 55-77, at least 30-pack–year smoking history, current smoker or former smoker who quit within the past 15 years). However, the overall uptake of LDCT is low, especially in health care settings with limited personnel and financial resources. To increase access to lung cancer screening services, the American Cancer Society partnered with 2 federally qualified health centers (FQHCs) in Tennessee and West Virginia to conduct a pilot project focused on developing and refining the LDCT screening referral processes and practices. Each FQHC was required to partner with an American College of Radiology–designated lung cancer screening center in its area to ensure high-quality patient care. The pilot project was conducted in 2 phases: 6 months of capacity building (January–June 2016) followed by 2 years of implementation (July 2016–June 2018). One site created a sustainable LDCT referral program, and the other site encountered numerous barriers and failed to overcome them. This case study highlights implementation barriers and factors associated with success and improved outcomes in LDCT screening.

Aims: Whether risk of worsening renal function (WRF) during acute heart failure (AHF) hospitalization or the association between in-hospital WRF and post-discharge outcomes vary according to left ventricular ejection fraction (LVEF) is uncertain. We assessed incidence of WRF, factors related to its development and impact of WRF on post-discharge outcomes across the spectrum of LVEF in patients enrolled in RELAX-AHF-2. Methods and results: A total of 6112 patients who had LVEF measured on admission and renal function determined prospectively during hospitalization were included. WRF, defined as a rise in serum creatinine ≥0.3 mg/dL from baseline through day 5, occurred in 1722 patients (28.2%). Incidence increased progressively from lowest to highest LVEF quartile (P < 0.001). After baseline adjustment, WRF risk in Q4 (LVEF >50%) remained significantly greater than in Q1 (LVEF ≤29%; hazard ratio 1.2, 95% confidence interval 1–1.43; P = 0.050). Age and comorbidity burden including chronic kidney disease increased as LVEF increased. Neither admission haemodynamic abnormalities, extent of diuresis during hospitalization nor residual congestion explained the increased incidence of WRF in patients with higher LVEF. Serelaxin treatment and diuretic responsiveness were associated with reduced risk of WRF in all LVEF quartiles. WRF in patients in the upper three LVEF quartiles increased risk of post-discharge events. Conclusions: Worsening renal function incidence during AHF hospitalization increases progressively with LVEF. Greater susceptibility of patients with higher LVEF to WRF appears more related to their advanced age and worse underlying kidney function rather than haemodynamic or treatment effects. WRF is associated with increased risk of post-discharge events except in patients in the lowest LVEF quartile. © 2020 European Society of Cardiology

Industrial chemical contamination within coastal regions of the Great Lakes can pose serious risks to wetland habitat and offshore fisheries, often resulting in fish consumption advisories that directly affect human and wildlife health. Mercury (Hg) is a contaminant of concern in many of these highly urbanized and industrialized coastal regions, one of which is the Saint Louis River estuary (SLRE), the second largest tributary to Lake Superior. The SLRE has legacy Hg contamination that drives high Hg concentrations within sediments, but it is unclear whether legacy-derived Hg actively cycles within the food web. To understand the relative contributions of legacy versus contemporary Hg sources in coastal zones, Hg, carbon, and nitrogen stable isotope ratios were measured in sediments and the food webs of SLRE and the Bad River, an estuarine reference site. Hg stable isotope values revealed that legacy contamination of Hg was widespread and heterogeneously distributed in sediments of SLRE, even in areas lacking industrial Hg sources. Similar isotope values were found in benthic invertebrates, riparian spiders, and prey fish from SLRE, confirming legacy Hg reaches the SLRE food web. Direct comparison of prey fish from SLRE and the Bad River confirmed that Hg isotope differences between the sites were not attributable to fractionation associated with rapid Hg bioaccumulation at estuarine mouths, but due to the presence of industrial Hg within SLRE. The Hg stable isotope values of game fish in both estuaries were dependent on fish migration and diet within the estuaries and extending into Lake Superior. These results indicate that Hg from legacy contamination is actively cycling within the SLRE food web and, through migration, this Hg also extends into Lake Superior via game fish. Understanding sources and the movement of Hg within the estuarine food web better informs restoration strategies for other impaired Great Lakes coastal zones.