Current state and practice variation in the use of Meningitis/Encephalitis (ME) FilmArray panel in children.

BACKGROUND: The Meningitis/Encephalitis FilmArray® Panel (ME panel) was approved by the U.S. Food and Drug Administration in 2015 and provides rapid results when assessing patients with suspected meningitis or encephalitis. These patients are evaluated by various subspecialties including pediatric hospital medicine (PHM), pediatric emergency medicine (PEM), pediatric infectious diseases, and pediatric intensive care unit (PICU) physicians. The objective of this study was to evaluate the current use of the ME panel and describe the provider and subspecialty practice variation. METHODS: We conducted an online cross-sectional survey via the American Academy of Pediatrics Section of Hospital Medicine (AAP-SOHM) ListServe, Brown University PEM ListServe, and PICU Virtual pediatric system (VPS) Listserve. RESULTS: A total of 335 participants out of an estimated 6998 ListServe subscribers responded to the survey. 68% reported currently using the ME panel at their institutions. Among test users, most reported not having institutional guidelines on test indications (75%) or interpretation (76%). 58% of providers self-reported lack of knowledge of the test's performance characteristics. Providers from institutions that have established guidelines reported higher knowledge compared to those that did not (51% vs. 38%; p = 0.01). More PHM providers reported awareness of ME panel performance characteristics compared to PEM physicians (48% vs. 27%; p = 0.004); confidence in test interpretation was similar between both groups (72 vs. 69%; p = 0.80). CONCLUSION: Despite the widespread use of the ME panel, few providers report having institutional guidelines on test indications or interpretation. There is an opportunity to provide knowledge and guidance about the ME panel among various pediatric subspecialties.

Hyaluronan suppresses prostate tumor cell proliferation through diminished expression of N-cadherin and aberrant growth factor receptor signaling.

Hyaluronan (HA) production has been functionally implicated in prostate tumorigenesis and metastasis. We previously used prostate tumor cells overexpressing the HA synthesizing enzyme HAS3 or the clinically relevant hyaluronidase Hyal1 to show that excess HA production suppresses tumor growth, while HA turnover accelerates spontaneous metastasis from the prostate. Here, we examined pathways responsible for effects of HAS3 and Hyal1 on tumor cell phenotype. Detailed characterization of cell cycle progression revealed that expression of Hyal1 accelerated cell cycle re-entry following synchronization, whereas HAS3 alone delayed entry. Hyal1 expressing cells exhibited a significant reduction in their ability to sustain ERK phosphorylation upon stimulation by growth factors, and in their expression of the cyclin-dependent kinase inhibitor p21. In contrast, HAS3 expressing cells showed prolonged ERK phosphorylation and increased expression of both p21 and p27, in asynchronous and synchronized cultures. Changes in cell cycle regulatory proteins were accompanied by HA-induced suppression of N-cadherin, while E-cadherin expression and ß-catenin expression and distribution remained unchanged. Our results are consistent with a model in which excess HA synthesis suppresses cell proliferation by promoting homotypic E-cadherin mediated cell-cell adhesion, consequently signaling to elevate cell cycle inhibitor expression and suppress G1- to S-phase transition.

Is implementation of a hospital pathway for high-flow nasal cannula initiation and weaning associated with reduced high-flow duration in bronchiolitis?

BACKGROUND: High-flow nasal cannula (HFNC) therapy is widely used for children with bronchiolitis, but its optimal role remains uncertain. Our institution created and later revised a clinical pathway guiding HFNC initiation and weaning. METHODS: A retrospective review of 1690 bronchiolitis encounters was conducted. Trends in the duration of HFNC and hours spent weaning HFNC as proportions of the monthly hospital length of stay (LOS) for bronchiolitis, hospital LOS, and escalation of care were compared using interrupted time series (ITS) models across three study periods: Baseline (HFNC managed at provider discretion), Intervention 1 (pathway with initiation at 0.5 L/kg/min and escalation up to 2 L/kg/min), and Intervention 2 (revised pathway, initiation at the maximum rate of 2 L/kg/min). Both pathway iterations provided titration and weaning guidance. Maximum respiratory scores were used to adjust for case severity. RESULTS: After adjustment for severity and time, both HFNC duration and HFNC weaning time (as a proportion of monthly LOS) decreased at the start of Intervention 1, but subsequently increased. During Intervention 2, both these measures trended downward, returning to baseline. Total LOS did not change in the baseline or intervention periods. Escalation of care did not differ from baseline to the end of Intervention 2. CONCLUSION: Initiating HFNC at higher flow rates with weaning guidance for children hospitalized with bronchiolitis was associated with a reduction in HFNC duration without differences in LOS or escalation of care. These findings suggest that standardization through clinical pathways can limit HFNC duration in bronchiolitis.

Evaluation of Discordant Results Between FilmArray Meningitis/Encephalitis Panel and Conventional Testing in Pediatric Patients: A Multisite Retrospective Cohort Study.

BACKGROUND: The FilmArray Meningitis/Encephalitis panel (MEP) has an 11% false-positive and 2.2% false-negative rate compared with conventional testing. We describe clinical characteristics, treatment decisions, and outcomes in children with discordant results between MEP and conventional testing. METHODS: We conducted a multisite review of patients ≤ 18 years with suspected central nervous system infection and positive results by MEP or conventional testing (cerebrospinal fluid [CSF] culture, herpes simplex virus [HSV] polymerase chain reaction (PCR), and enterovirus [EV] PCR). Descriptive results are provided for patients with discordant results. Comparison between group 1 (MEP and CSF culture positive) and group 2 (MEP positive, CSF culture negative, or showing a different pathogen) was made by Mann-Whitney test for continuous and Fisher's test for categorical variables. RESULTS: A total of 355 patients had at least one pathogen identified. More than half of patients with bacterial pathogens identified that are included in the MEP had discordant results (30/52; 58%). There were 28 samples with bacterial pathogen identified on MEP only, 1 with different bacterial pathogens on MEP and culture, and 1 with Escherichia coli identified on CSF culture only. Patients in group 1 were more likely to have CSF pleocytosis, elevated CSF protein, and decreased CSF glucose than group 2 (P < .05). Two patients were HSV positive by MEP while HSV negative by PCR. Ten patients had discordant results between MEP and EV PCR. CONCLUSIONS: Discordant results between MEP and conventional testing are common. Treatment decisions based on a positive MEP should be made in the appropriate clinical context.

Quality Improvement of Primary Care Provider Communication on Hospital Discharge.

BACKGROUND AND OBJECTIVES: Effective communication between inpatient and primary care providers (PCPs) is important for safe transition of care for hospitalized patients. In 2017, communication with PCPs was prioritized for the pediatric hospital medicine division. Our primary aim was to improve documented attempted communication with PCPs within 72 hours of discharge from 41% to at least 60% by January 1, 2018, and maintain this performance through 2019. METHODS: This study included all inpatient encounters discharged by a pediatric hospital medicine provider from March 2017 to April 2020. An electronic health record phrase debuted March 2017. Successful documentation was defined as any attempt to contact the PCP, regardless of whether actual communication occurred. Group and individual audit and feedback occurred in July 2017 to April 2020. Provider communication was financially incentivized in July 2018 to June 2019. An annotated P-chart for the proportion of encounters with documented PCP communication occurring within 72 hours was established. Special-cause variation was determined by using Shewhart rules. RESULTS: The mean proportion of encounters with documented PCP communication increased from 41% at baseline (March 2017 through July 2017) to 60% in August 2017 and 66% in December 2017. After the financial incentive was removed in July 2019, documentation decreased to 54%. Phone calls with clinic staff were the most common communication method (40% to 71%). Direct conversations with the PCP occurred rarely (0% to 3%). CONCLUSIONS: Even when coupled with audit and feedback with EHR interventions, our work suggests that shifting to external financial motivation may hinder sustainability of behavior change to improve attempted documented PCP communication.

Learner perceptions of family-centred rounds.

BACKGROUND: Family-centred rounds (FCRs) are common in paediatric inpatient medicine. FCRs lead to shorter hospital stays, improved communication, and improved patient and family satisfaction. Rounding structures can differ between institutions based on participants, the location of rounds and the role of trainees. The aim of our study was to compare walking hallway rounds with a new conference-room rounding style, as measured by learner perceptions of FCRs. METHODS: All students participating in FCRs on two hospitalist teams were included in this study. In October 2017, a family-centred conference-room rounding model was developed. Team A adopted conference-room rounds whereas team B continued to use hallway rounds. Student and resident evaluations were constructed using a nine-point Likert scale (1, strongly disagree; 9, strongly agree). Evaluations assessed various perceived components of rounding. RESULTS: There were statistically significant differences between the evaluation responses from student team A (n = 21) versus student team B (n = 32) regarding perceived comfort in presenting (A = 7.86, B = 6.56, t = 3.42, p ≤ 0.001), confidence talking to families about medical decision making (A = 7.19, B = 6.32, t = 2.57, p = 0.013), educational value of rounds (A = 8.05, B = 6.16, z = -4.39, p ≤ 0.0001), value as a team member (A = 7.38, B = 6.34, z = -2.22, p = 0.013) and preparedness to round (A = 7.76, B = 6.34, z = -3.67, p ≤ 0.0001). Among residents, there were statistically significant differences regarding the perceived efficiency of rounds (A = 6.69, B = 4.89, t = 2.09, p = 0.048) and family engagement (A = 7.81, B = 5.89, z = -2.67, p = 0.003). DISCUSSION: Compared with hallway rounds, students and residents had improved learner perceptions of FCRs when participating in conference-room rounds. Some component of conference room rounding may be beneficial to learners while maintaining family-centered care.

IDeA States Pediatric Clinical Trials Network for Underserved and Rural Communities.

The National Institutes of Health's Environmental Influences on Child Health Outcomes (ECHO) program aims to study high-priority and high-impact pediatric conditions. This broad-based health initiative is unique in the National Institutes of Health research portfolio and involves 2 research components: (1) a large group of established centers with pediatric cohorts combining data to support longitudinal studies (ECHO cohorts) and (2) pediatric trials program for institutions within Institutional Development Awards states, known as the ECHO Institutional Development Awards States Pediatric Clinical Trials Network (ISPCTN). In the current presentation, we provide a broad overview of the ISPCTN and, particularly, its importance in enhancing clinical trials capabilities of pediatrician scientists through the support of research infrastructure, while at the same time implementing clinical trials that inform future health care for children. The ISPCTN research mission is aligned with the health priority conditions emphasized in the ECHO program, with a commitment to bringing state-of-the-science trials to children residing in underserved and rural communities. ISPCTN site infrastructure is critical to successful trial implementation and includes research training for pediatric faculty and coordinators. Network sites exist in settings that have historically had limited National Institutes of Health funding success and lacked pediatric research infrastructure, with the initial funding directed to considerable efforts in professional development, implementation of regulatory procedures, and engagement of communities and families. The Network has made considerable headway with these objectives, opening two large research studies during its initial 18 months as well as producing findings that serve as markers of success that will optimize sustainability.

Association of the FilmArray Meningitis/Encephalitis Panel With Clinical Management.

OBJECTIVES: To determine the association of the use of the multiplex assay meningitis/encephalitis panel with clinical management of suspected meningitis. METHODS: A cross-sectional study was conducted with children 0 to 18 years of age who received a lumbar puncture within 48 hours of admission for an infectious workup. Patient demographic and presenting information, laboratory studies, and medication administration were collected. The primary measure was length of stay (LOS) with secondary measures: time on antibiotics, time to narrowing antibiotics, and acyclovir doses. LOS and antibiotic times were stratified for outcomes occurring before 36 hours. Logistic regression analysis was used to account for potential confounding factors associated with both the primary and secondary outcomes. A value of P < .05 was considered statistically significant. RESULTS: Meningitis panel use was associated with a higher likelihood of a patient LOS <36 hours (P = .04; odds ratio = 1.7; 95% confidence interval [CI]: 1.03-2.87), a time to narrowing antibiotics <36 hours (P = .008; odds ratio = 1.89; 95% CI: 1.18-2.87), and doses of acyclovir (P < .001; incidence rate ratio = 0.37; 95% CI: 0.26-0.53). When controlling for potential confounding factors, these associations persisted. CONCLUSIONS: Use of the meningitis panel was associated with a decreased LOS, time to narrowing of antibiotics, and fewer acyclovir doses. This likely is a result of the rapid turnaround time as compared with cerebrospinal fluid cultures. Additional studies to examine the outcomes related to this change in management are warranted.