Practical quality improvement changes for a low-resourced pediatric unit.

Background: This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative. Methods: This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions. Results: 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components. Conclusion: Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Sustainable improvement in upstream and downstream outcomes for intubated patients three years after an airway-based educational intervention in a low-resource pediatric intensive care unit.

OBJECTIVE: To determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a low-resource country. DESIGN: Quality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3). SETTING: PICU of the largest public children's hospital in El Salvador. PATIENTS: 147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)). INTERVENTION: A low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2-55.1 % in Epoch 3 (p = 0.003, z-score -2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15-0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48-2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention. CONCLUSIONS: Sustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.

Publications on COVID-19 in radiology journals in 2020 and 2021: bibliometric citation and co-citation network analysis.

OBJECTIVES: The pandemic caused by SARS-CoV-2 has led to the rapid publication of numerous radiology articles, primarily focused on disease diagnosis. The objective of this study is to analyze the intellectual structure of radiology research on COVID-19 using a citation and co-citation analysis. METHODS: We identified all documents about COVID-19 published in radiology journals included in the Web of Science in the period 2020-2021, conducting a citation analysis. Then we identified all bibliographic references that were cited by these documents, generating a co-citation matrix that was used to perform a co-citation network. RESULTS: Of the 3418 documents indexed in WoS, 857 were initially "Early Access," 2223 had citations, 393 had more than 20 citations, and 83 had more than 100 citations. The USA had the highest number of publications (32.62%) and China had the highest rate of funded studies (45.38%). The three authors with the most publications were affiliated with Italian institutions, while the five most cited authors were Chinese. A total of 647 publications were co-cited at least 12 times and were published in 206 different journals, with 49% of the documents found in radiology journals. The institutions with the greatest presence among these co-cited articles were Chinese and American. CONCLUSION: This co-citation analysis is the first to focus exclusively on radiology articles on COVID-19. Our study confirms the existence of interrelated thematic clusters with different specific weights. KEY POINTS: • As the pandemic caused by SARS-Cov-2 has led to the rapid publication of numerous radiology studies in a short time period, a bibliometric review based on citation and co-citation analysis has been conducted. • The co-citation analysis supported the identification of key themes in the study of COVID-19 in radiology publications. • Many of the most co-cited articles belong to a heterogeneous group of publications, with authors from countries that are far apart and even from different disciplines.

A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units.

INTRODUCTION: Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU. METHODS: This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was $1.32 per child. PICU mortality was evaluated as an exploratory outcome. RESULTS: Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28-0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17-0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24-0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is $30.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44. CONCLUSION: This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.

A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience.

OBJECTIVE: To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. STUDY DESIGN: Consecutive case series with chart review. SETTING: This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. METHODS: Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. RESULTS: A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. CONCLUSION: This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

Congenital nasal piriform aperture atresia: A case report and novel finding.

Congenital nasal piriform aperture stenosis and choanal atresia are types of nasal obstructions that can be life threatening to infants if left untreated. While there has been numerous reports on both of them there has not been a single reported case of congenital nasal piriform aperture atresia. Here, we present the first case of piriform aperture atresia that includes the diagnostic and clinical approach.

Anticancer activities of two sesquiterpene lactones, millerenolide and thieleanin isolated from Viguiera sylvatica and Decachaeta thieleana.

The present study was carried out in order to examine the anticancer properties of two sesquiterpene lactones, millerenolide and thieleanin, isolated from Viguiera sylvatica and Decachaeta thieleana, against cell lines in vitro, and on the growth B16/BL6 melanoma tumors in C57BL/6 mice. Millerenolide and thieleanin showed a similar pattern of cytotoxicity with the greatest effect on viability being evident with A549 human lung cancer cells (IC(50) - 40 and 32 microM respectively), and with the 3T3/HER2 cell line which are 3T3 mouse fibroblasts transfected with the HER2 oncogene (IC(50) - 16 and 28 microM respectively). The parent 3T3 cells and the B16/BL6 mouse melanoma cells were less sensitive to these compounds, with thieleanin showing an IC(50) with B16/BL6 greater than the highest dose tested (203 microM). Treatment with millerenolide (8 mg/kg, i.p. on days 0, 2 and 4 post-inoculation) significantly inhibited the growth of subcutaneous B16/BL6 tumors in C57BL/6 mice, (50% inhibition at day 25, P=0.015), as well as retarding the appearance of detectable tumor (millerenolide - day 15.2+/-0.4 vs control - day 12.8+/-0.5, mean+/-SEM, P=0.011). In contrast, treatment with thieleanin (8 mg/kg every other day up to the day of kill) neither retarded the appearance of the tumor nor its growth.

[Sesquiterpene lactones of the plants Viguiera sylvatica and Decachaeta thieleana (Asteraceae) modulate nitric oxide production and phagocytosis of macrophages cell line RAW]. / Lactonas sesquiterpénicas de las plantas Viguiera sylvatica y Decachaeta thieleana (Asteraceae) modulan la producción de oxido nítrico y la fagocitosis de macrófagos RAW.

Different species of the Asteraceae family are a potential source of sesquiterpene lactones with anti-inflammatory properties. Macrophages play a central role in the regulation of immune responses. In the present study, the in vitro effect of two sesquiterpene lactones, a millerenolide and a thieleanin, was assessed by measuring the production of nitric oxide (NO) by cell line RAW (murine macrophages) using the Griess reagent. Additionally, the effect of these sesquiterpene lactones on phagocytic capacity of latex particles and the reduction of nitroblue tetrazolium (NBT) were evaluated microscopically. Treatment of macrophages with > 2.5 microg/ml of both sesquiterpene lactones, reduced the production of NO. A decreased number of macrophages able to reduce NBT were observed when these cells were treated with 3 microg/ml of millerenolide or 7.5 microg/ml of thieleanin. Treatment of macrophages with 4 microg/ml ofmillerenolide or 7.5 microg/ml of thieleanin, reduced the phagocytic capacity of macrophages. Cytotoxic effects on the macrophages were only observed when the concentration was increased to 8 microg/ml of millerenolide or 25 microg/ml of thieleanin. Our results suggest that these sesquiterpene lactones could be useful compounds in the elaboration of anti-inflammatory drugs.

Pharyngitis.

Preview Depending on the cause, pharyngitis may be a relatively benign symptom or an ominous harbinger of severe sequelae, including rheumatic fever. Therefore, accurate diagnosis and appropriate treatment are important to avoid potentially serious complications. Drs Bonilla and Bluestone discuss the most common causes of pharyngitis, the diagnostic workup, and the current symptomatic and antimicrobial therapies. Treatment of recurrent tonsillitis is also included.

Modificación de un método colorimétrico que usa XTT, para la determinación de linfoproliferación / Modification of a colorimetric method using XTT, for determination of lymphoproliferation

Los métodos para la determinación de proliferación celular se han basado tradicionalmente en la incorporación y detección de productos marcados con radioactividad. En este trabajo se describe una modificación de una técnica colorimétrica capaz de detectar la linfoproliferación. El estudio se llevó a cabo con linfocitos de 23 estudiantes universitarios voluntarios aparentemente sanos y se obtuvieron diferentes significativas (Tt>Tc) entre linfocitos estimulados y no estimulados. El método permite cuantificar la linfoproliferación por medio de una medición espectrofotométrica directa en un lector de ELISA. El número de células presente en cada pozo correlaciona con la capacidad de reducir la sal de tetrazol (XTT) a un producto coloreado y soluble. La sal es reducida principalmente por la actividad enzimática mitocondrial presente básicamente en las células vivas. La técnica presenta las ventajas de ser simple, económica y segura si se compara con los métodos que emplean radioactividad comúnmente usados; esto podría facilitar su introducción en Costa Rica, en los laboratorios de investigación y en el área hospitalaria, para el apoyo en el diagnóstico de problemas del sistema inmune.