Review of Urinary Tract Infections and Pyelonephritis.

Urinary tract infections (UTIs) are serious bacterial infections affecting children of all ages. An understanding of the methods of urine collection is important to prevent the contamination of urine specimens and to interpret results. The diagnosis of a UTI requires appropriate interpretation of both urinalysis and urine culture results because testing must indicate evidence of inflammation and the presence of bacteria. Rapid treatment of UTIs is imperative to prevent acute decompensation and systemic illness. Empiric antibiotics should be narrowed as soon as possible to tailor antibiotic treatment and limit antibiotic overuse. Imaging with a renal ultrasound scan is recommended for all infants with first febrile UTIs rather than a voiding cystourethrogram. An additional goal of UTI treatment is to prevent renal scarring, which can lead to lifelong health consequences. Children with anatomic abnormalities of the urinary tract and those who have recurrent UTIs are at increased risk of renal scarring. [Pediatr Ann. 2024;53(6):e217-e222.].

Development and validity evidence for the resident-led large group teaching assessment instrument in the United States: a methodological study.

PURPOSE: Despite educational mandates to assess resident teaching competence, limited instruments with validity evidence exist for this purpose. Existing instruments do not allow faculty to assess resident-led teaching in a large group format or whether teaching was interactive. This study gathers validity evidence on the use of the Resident-led Large Group Teaching Assessment Instrument (Relate), an instrument used by faculty to assess resident teaching competency. Relate comprises 23 behaviors divided into six elements: learning environment, goals and objectives, content of talk, promotion of understanding and retention, session management, and closure. METHODS: Messick's unified validity framework was used for this study. Investigators used video recordings of resident-led teaching from three pediatric residency programs to develop Relate and a rater guidebook. Faculty were trained on instrument use through frame-of-reference training. Resident teaching at all sites was video-recorded during 2018-2019. Two trained faculty raters assessed each video. Descriptive statistics on performance were obtained. Validity evidence sources include: rater training effect (response process), reliability and variability (internal structure), and impact on Milestones assessment (relations to other variables). RESULTS: Forty-eight videos, from 16 residents, were analyzed. Rater training improved inter-rater reliability from 0.04 to 0.64. The Φ-coefficient reliability was 0.50. There was a significant correlation between overall Relate performance and the pediatric teaching Milestone, r = 0.34, P = .019. CONCLUSION: Relate provides validity evidence with sufficient reliability to measure resident-led large-group teaching competence.

Effects of a Poetry Intervention on Emotional Wellbeing in Hospitalized Pediatric Patients.

BACKGROUND AND OBJECTIVES: The hospital is often a challenging and unfamiliar environment for families. Hospitalization can increase stress and anxiety among children and caregivers. In this study, we are the first to explore the possible therapeutic effects of poetry on hospitalized pediatric patients' emotional wellbeing. PATIENTS AND METHODS: Patients aged 8 to 17 years old admitted to the inpatient pediatric ward and their parents or guardians were eligible for inclusion. With the validated Pediatric Quality of Life Present Functioning Visual Analogue Scales, 6 items were measured before and after the poetry intervention for each participant: fear, sadness, anger, worry, fatigue, and pain in the present moment. The intervention itself consisted of poetry-based reading and writing exercises. Participants and parents also completed an open-ended qualitative survey on their experience. RESULTS: Data from 44 participants were analyzed. Using the Wilcoxon signed rank test, we showed that the poetry intervention had a statistically significant reduction in 5 of the 6 Pediatric Quality of Life Present Functioning Visual Analogue Scales symptom measures: fear (P = .021), sadness (P = .004), anger (P = .039), worry (P = .041), and fatigue (P < .001). Reduction in pain was not statistically significant (P = .092). Six coded themes emerged from qualitative analysis: the poetry intervention facilitated (1) happiness and (2) family involvement, was viewed as a (3) good distraction and (4) screenless activity, and cultivated (5) creativity and (6) self-reflection. CONCLUSIONS: The poetry intervention led to statistically significant reductions in fear, sadness, anger, worry, and fatigue but not in pain. The study reveals promising results and serves as a starting point for future investigations on the therapeutic impact of poetry on hospitalized pediatric patients.

Early and Significant Reduction in C-Reactive Protein Levels After Corticosteroid Therapy Is Associated With Reduced Mortality in Patients With COVID-19.

BACKGROUND: Corticosteroids may be beneficial in a subset of patients with coronavirus disease 2019 (COVID-19), but predictors of therapeutic response remain unknown. C-reactive protein (CRP) is a routinely measured biomarker, and reduction in its levels after initiation of therapy may predict inpatient mortality. METHODS: In this retrospective cohort study, the charts of patients who were admitted to Montefiore Medical Center between March 10, 2020, and May 2, 2020 for the management of COVID-19 were examined. Of all patients who met inclusion criteria, patients who received corticosteroid treatment were categorized as CRP responders (≥50% CRP level reduction) and CRP nonresponders (<50% CRP level reduction) based on change in CRP within 72 hours of corticosteroid treatment initiation. The outcomes of interest were two-fold: (1) CRP response after treatment with corticosteroid, and (2) differences in mortality among patients with CRP response compared those without. RESULTS: Of 2,707 patients admitted during the study period, 324 received corticosteroid treatment. Of patients who received corticosteroid treatment, CRP responders had reduced risk of death compared with risk among CRP nonresponders (25.2% vs 47.8%; unadjusted odds ratio [OR], 0.37; 95% CI, 0.21-0.65; P <.001). This effect remained strong and significant after adjustment for potential confounders (adjusted OR, 0.27; 95% CI, 0.14-0.54; P <.001). CONCLUSION: Reduction in CRP by 50% or more within 72 hours of initiating corticosteroid therapy potentially predicts inpatient mortality. This may serve as an early biomarker of response to corticosteroid therapy in patients with COVID-19.

Work-Life Balance and Career Experiences of Part-Time Versus Full-Time Faculty at the Warren Alpert Medical School of Brown University.

INTRODUCTION: Part-time faculty are an important part of the academic medical workforce, comprising 11-21% of faculty in some institutions. OBJECTIVE: To describe the part-time faculty experience at a single institution across four domains: work-life balance, work environment, leadership and advancement, and mentorship. METHODS: Faculty from the Division of Biology and Medicine at Brown University were invited to participate in an electronic survey. The authors compared responses between full-time and part-time faculty across the four domains.   Results: Survey response rate was 43% (437/1025). Of the 363 who answered the question about employment status, 333 (92%) were full-time and 30 (8%) were part-time. Part-time faculty were less likely to report forgoing personal activities for professional responsibilities, that work conflicted with personal life, that their division director took interest in their careers, and having a leadership position was important to them. CONCLUSION: Part-time and full-time faculty reported significant differences in perception of work impact on personal life, division director support, and desire for leadership positions.

The Development of an Instrument for Faculty to Assess Resident-Led Large Group Teaching.

OBJECTIVE: The Accreditation Council on Graduate Medical Education requires residents to teach and many residency programs assess resident teaching competency. While much formal resident-led teaching is for large groups, no corresponding published assessment instrument with validity evidence exists. We developed an instrument for faculty to assess pediatric resident-led large group teaching and gathered preliminary validity evidence. METHODS: Literature review and our experience leading resident-as-teacher curricula informed initial instrument content. Resident focus groups from 3 northeastern pediatric residency programs provided stakeholder input. A modified Delphi panel of international experts provided iterative feedback. Three investigators piloted the instrument in 2018; each assessed 8 video recordings of resident-led teaching. We calculated Cronbach's alpha for internal consistency and intraclass correlation (ICC) for inter-rater reliability. RESULTS: The instrument has 6 elements: learning climate, goals/objectives, content, promotion of understanding/retention, session management, and closure. Each element contains behavioral subelements. Cronbach's alpha was .844. ICC was excellent for 6 subelements, good for 1, fair for 1, and poor for 3. CONCLUSIONS: We developed an instrument for faculty assessment of resident-led large group teaching. Pilot data showed assessed behaviors had good internal consistency, but inconsistent interrater reliability. With further development, this instrument has potential to assess resident teaching competency.

Single-chromosome Gains Commonly Function as Tumor Suppressors.

Aneuploidy is a hallmark of cancer, although its effects on tumorigenesis are unclear. Here, we investigated the relationship between aneuploidy and cancer development using cells engineered to harbor single extra chromosomes. We found that nearly all trisomic cell lines grew poorly in vitro and as xenografts, relative to genetically matched euploid cells. Moreover, the activation of several oncogenic pathways failed to alleviate the fitness defect induced by aneuploidy. However, following prolonged growth, trisomic cells acquired additional chromosomal alterations that were largely absent from their euploid counterparts and that correlated with improved fitness. Thus, while single-chromosome gains can suppress transformation, the genome-destabilizing effects of aneuploidy confer an evolutionary flexibility that may contribute to the aggressive growth of advanced malignancies with complex karyotypes.

Nonsteroidal Anti-Inflammatory Drug Toxicity in Children: A Clinical Review.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most widely used classes of medications in children. Despite a reported positive safety profile, NSAIDs have been associated with toxicities in both overdose and routine use. Most children with NSAID overdoses are asymptomatic and should be managed conservatively, whereas a small number may present with severe symptoms. We review NSAID exposures in children and strategies for their clinical evaluation and management.

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.

IMPORTANCE: Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. OBJECTIVE: To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. DESIGN, SETTING, AND PARTICIPANTS: Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. INTERVENTIONS: Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. MAIN OUTCOMES AND MEASURES: The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. RESULTS: Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention. CONCLUSIONS AND RELEVANCE: Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.

Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease?

BACKGROUND: It has become common practice to empirically treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications. However, evidence to support the effectiveness of these medications in the pediatric population is limited. With multiple studies in adult patients indicating increased risk of infection, we reviewed the literature to determine the association between acid-suppressive medications and serious adverse effects in infants and children. METHODS: We conducted a PubMed search on the adverse effects of H2 antagonists and proton pump inhibitors in pediatric patients. The studies selected were original research and systematic reviews with control groups and study objectives evaluating the relationship between acid-suppressive medications and serious adverse effects (namely, infections). RESULTS: Fourteen studies met our inclusion criteria. The majority of studies found a significant association between acid-suppressive medications and the risk of necrotizing enterocolitis, sepsis/bacteremia, pneumonia, and gastrointestinal infections in infants and children. CONCLUSIONS: Given the questionable efficacy of H2 antagonists and proton pump inhibitors and the growing evidence of increased risk of serious infections, acid-suppressive medications should be used cautiously in infants and children suspected of having gastroesophageal reflux disease.

Influenza vaccination, diagnosis, and treatment in children.

Between 2009 and 2010, the influenza H1N1 pandemic swept across the globe, disproportionately affecting the pediatric population. This pandemic strain is expected to circulate again with other seasonal influenza strains during the 2010-2011 season. This article reviews the new 2010 to 2011 Centers for Disease Control and Prevention and American Academy of Pediatrics recommendations for vaccination against the influenza virus for pediatric patients. It reviews the various testing modalities and the benefits and disadvantage of each test and offers an approach to diagnostic testing. Lastly, it reviews the indications and recommendations for treatment of children with presumed or confirmed influenza infection.

Safety of influenza vaccine administration in egg-allergic patients.

OBJECTIVE: Current guidelines recommend that egg-allergic patients receive an influenza vaccine skin test before the influenza vaccine. This study evaluated the safety of bypassing the skin test and administering graded doses of influenza vaccine to egg-allergic children. METHODS: We conducted a retrospective chart-review study of egg-allergic patients aged 6 months to 18 years who received the vaccine skin test and/or a 2-dose graded influenza vaccine. Between influenza seasons 2002-2003 and 2006-2007, egg-allergic patients underwent a vaccine skin test before influenza vaccine administration. Starting in 2006-2007, the skin test was removed from our protocol and egg-allergic patients received the influenza vaccine in 2 graded doses. All vaccinated patients were observed for adverse reactions. RESULTS: Two hundred sixty-one egg-allergic patients were evaluated for influenza vaccine administration, and 171 went on to receive the vaccine. Of the 56 patients who received the skin test before the influenza vaccine, 95% (exact 95% confidence interval [CI]: 85.1-98.9) tolerated the vaccine without a serious adverse reaction. This rate was unchanged after the vaccine skin test was removed from the protocol. Of the 115 patients who received the vaccine without a preceding skin test, 97% (exact 95% CI: 91.3-99.0) tolerated the vaccine without serious adverse reaction. The tolerance rate ratio was 1.01 (95% CI: 0.97-1.06). CONCLUSION: The results of our study suggest that egg-allergic patients without anaphylaxis to egg may safely receive the influenza vaccine in a 2-dose, graded fashion without a vaccine skin test.

Echocardiographic features of patients with heart failure who may benefit from biventricular pacing.

BACKGROUND: Recent studies suggest that cardiac resynchronization therapy through biventricular pacing (BVP) may be a promising new treatment for patients with advanced congestive heart failure (CHF). This method involves implantation of pacer leads into the right atrium (RA), right ventricle (RV), and coronary sinus (CS) in patients with ventricular dyssynchrony as evidenced by a bundle branch block pattern on electrocardiogram (ECG). Clinical trials are enrolling stable patients with ejection fractions (EF) /= 54 mm, and QRS duration >/=140 msec. We compared echocardiography features of these patients (group 1) with other patients with EF /= 54 mm, and QRS < 140 msec (group 2 = presumably no dyssynchrony). METHODS: Nine hundred fifty-one patients with CHF, LVID 54 mm, EF 35% by echocardiography were retrospectively evaluated. One hundred forty-five patients remained after those with primary valvular disease, prior pacing systems, or chronic atrial arrhythmias were excluded. From this group of 145 patients, a subset of 50 randomly selected patients were further studied (25 patients [7 females, 18 males] from group 1, and 25 patients [7 females, 18 males] from group 2). Mean age group 1 = 75 years old, mean age group 2 = 67 years old. Mean QRS group 1 = 161 msec, mean QRS group 2 = 110 msec. Each group was compared for presence of paradoxical septal motion, atrial and ventricular chamber sizes, LV mass, LVEF, and RV systolic function. RESULTS: Of the initial group of 951 patients, 145 (15%) met inclusion criteria. In the substudy, 20/25 (80%) of group l and 7/25 (28%) of group 2 subjects had paradoxical septal motion on echo (Fisher's exact test, P = 0.0005). The t-tests performed on the other echocardiography variables demonstrated no differences in chamber size, function, or LV mass. CONCLUSIONS: Cardiac resynchronization therapy with BVP appears to target a relatively small population of our advanced CHF patients (15% or less). Although increasing QRS duration on ECG is associated with more frequent paradoxical septal motion on echo, it is not entirely predictive. Paradoxical septal motion on echo may therefore be more sensitive at identifying patients who respond to BVP. Further prospective studies are needed.

Intracardiac echocardiography using the AcuNav ultrasound catheter during percutaneous balloon mitral valvuloplasty.

During the past 10 years, there has been a trend toward and an interest in the use of catheter-based interventions to perform procedures that were once only approached surgically. The problem with the catheter-based approach has been procedure-related complications. Improved imaging of cardiac structures while undertaking interventional procedures may help to prevent or allow for early identification of these complications. Transesophageal echocardiography has been used during catheter-based procedures as a guide, and has both advantages and disadvantages. Intracardiac echocardiography is a relatively new imaging technique that also provides an enhanced view of cardiac structures and may also allow for the safe and efficient performance of catheter-based procedures. We report the first case of successful percutaneous balloon mitral valvuloplasty done under ultrasound guidance using an intracardiac echocardiography catheter (10F, 5-10 MHz) (Acunav). The strengths and weaknesses of this approach are described and compared with transesophageal echocardiography and older intracardiac echocardiography devices.