A Quality Improvement Initiative to Increase Hand Hygiene Awareness and Compliance in a Neonatal Intensive Care Unit in Haiti.

INTRODUCTION: Healthcare-associated infections (HCAI) are major causes of morbidity, mortality, increased lengths of stay and are an economic burden on healthcare systems in resources-limited settings. This is especially true for neonates, who are more susceptible with underdeveloped immune systems. Hand hygiene (HH) is a key weapon against HCAI, yet globally, HH compliance remains substandard. This study sought to determine the compliance with HH among healthcare workers (HCWs) in a children's hospital neonatal intensive care unit (NICU) in Haiti. METHODS: A HH educational intervention was performed in the NICU, including lectures and posters. Pre- and post-intervention HH data were collected on HCWs and parents using the World Health Organization '5 Moments for HH'. Data were analyzed using standard statistical analysis. RESULTS: HH increased in all HCW roles but not in parents. Correct HH increased in all groups, including parents. HH was more likely to occur prior to patient contact than after patient contact. Correct HH was more likely to occur with alcohol-based hand rub than with soap and water. CONCLUSION: This study demonstrates that an inexpensive and simple intervention can significantly increase HH compliance in a resource-limited NICU, which may lead to decreased rates of hospital-acquired sepsis. Parents, however, due to cultural norms as well as literacy and language barriers, need targeted educational interventions distinct from those that HCW benefit from.

Prediction of Adverse Outcomes in Pediatric Acute Hematogenous Osteomyelitis.

BACKGROUND: Clinicians cannot reliably predict complications of acute hematogenous osteomyelitis (AHO). METHODS: Consecutive cases of AHO from 2 pediatric centers in the United States were analyzed retrospectively to develop clinical tools from data obtained within 96 hours of hospitalization to predict acute and chronic complications of AHO. Two novel composite prediction scores derived from multivariable logistic regression modeling were compared with a previously published severity of illness (SOI) score, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) using area under the receiver operating characteristic curve analyses. RESULTS: The causative organisms were identified in 73% of 261 cases. Bacteremia (45%), abscesses (38%), and associated suppurative arthritis (23%) were relatively common. Acute or chronic complications occurred in 24% and 11% of patients, respectively. Multivariable logistic regression identified bone abscess (odds ratio [OR], 2.3 [95% confidence interval {CI}, 1.0-5.2]), fever > 48 hours (OR, 2.7 [95% CI, 1.2-6.0]), suppurative arthritis (OR, 3.2 [95% CI, 1.3-7.5]), disseminated disease (OR, 4.6 [95% CI, 1.5-14.3]), and delayed source control (OR, 5.1 [95% CI, 1.4-19.0]) as strong predictors of acute complications. In a separate model, CRP ≥ 100 mg/L at 2-4 days after antibiotics (OR, 2.7 [95% CI, 1.0-7.3]), disseminated disease (OR, 3.3 [95% CI, 1.1-10.0]), and requirement for bone debridement (OR, 6.7 [95% CI, 2.1-21.0]) strongly predicted chronic morbidity. These variables were combined to create weighted composite prediction scores for acute (A-SCORE) and chronic (C-SCORE) osteomyelitis, which were superior to SOI, CRP, and ESR and had negative predictive values > 90%. CONCLUSIONS: Two novel composite clinical scores were superior to existing tools to predict complications of pediatric AHO.

Antibiotic Prescribing Patterns Across the Continuum of Care for Children Hospitalized With Community-Acquired Pneumonia.

OBJECTIVES: The aim of this study was to describe the variation in antibiotic prescribing practices for uncomplicated community-acquired pneumonia across the continuum of care for hospitalized pediatric patients to better inform future efforts at standardizing antibiotic therapy throughout a single hospitalization. METHODS: This is a retrospective cohort study involving 4 hospitals caring for children aged 3 months to 18 years, hospitalized between January 1, 2011, and December 31, 2012, with diagnosis of uncomplicated pneumonia and without complex chronic medical conditions.Data collected include antibiotics prescribed before hospitalization, at the emergency department (ED) encounter, during hospitalization, and at hospital discharge. RESULTS: Six hundred nine children met inclusion criteria, with a mean age of 5.3 years and median length of stay of 2 days. Emergency department providers prescribed narrow-spectrum therapy 27% of the time, whereas discharging providers prescribed narrow-spectrum therapy 56% of the time. Third- and fourth-generation cephalosporins were less often prescribed in the preadmission setting and at discharge but were more often prescribed in the ED and inpatient setting. There was an association between inpatient prescription of broad-spectrum antibiotics when a blood culture was obtained, when broad-spectrum antibiotics were prescribed in the ED, and with increasing length of stay. CONCLUSION: Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.

Neonatal Sepsis in Haiti.

Infections (including sepsis, meningitis, pneumonia and tetanus) stand as a major contributor to neonatal mortality in Haiti (22%). Infants acquire bacteria that cause neonatal sepsis directly from the mother's blood, skin or vaginal tract either before or during delivery. Nosocomial and environmental pathogens introduce further risk after delivery. The absence of cohesive medical systems and methods for collecting information limits the available data in countries such as Haiti. This study seeks to add more information on the burden of severe bacterial infections and their etiology in neonates of Haiti. Researchers conducted a secondary retrospective analysis of a de-identified database from the Neonatal Intensive Care Unit (NICU) at Nos Petit Frères et Soeurs-St. Damien Hospital (NPFS-SDH). Records from 1292 neonates admitted to the NICU at NPFS-SDH in Port-au-Prince Haiti from 2013 to 2015 were reviewed. Sepsis accounted for 708 of 1292 (54.8%) of all admissions to the NICU. Infants admitted for sepsis had a mortality rate of 23% (163 of 708 infants admitted for sepsis). The most common organism cultured was Streptococcus agalactiae, followed by Klebsiella pneumoniae, Pseudomonas aeroginusa, Enterobacter aerogenes, Staphylococcus aureus and Proteus mirabillis Failure to order or obtain a culture was associated with an increased fatality (odds ratio 2.4) for infants with sepsis. Resistance should be a concern when treating empirically.

Anti-SARS-CoV-2 Monoclonal Antibodies in Pediatrics: Statewide Experience in Rhode Island.

BACKGROUND: The pediatric population has suffered COVID-19 infections with measurable morbidity and mortality. Without oral options in those less than 12 years of age, practical treatment in this rapidly evolving disease is necessary. One treatment modality is monoclonal antibodies. Limited information describes the efficacy and safety of anti-SARS-CoV-2 monoclonal antibodies in pediatrics. This is the largest case series addressing efficacy and safety of monoclonal antibodies in this population. OBJECTIVE: To report patient characteristics, side effects encountered, and hospital admissions or emergency department visits within 30 days following treatment. DESIGN: This retrospective case series includes high-risk pediatric COVID-19 patients who received monoclonal antibody infusions in a tertiary care center as outpatients between January 2021 and January 2022. OUTCOMES: There were 108 patients included with seven patients (6.5%) having infusion-related reactions with no other adverse events reported. Following the monoclonal treatment, three patients presented to the emergency department for worsening symptoms, and one patient was admitted to the pediatric ICU for worsening respiratory status. No other admissions or emergency department visits were reported in the one month following the infusion. CONCLUSIONS: In this case series study, monoclonal antibody infusions were well tolerated.

Mortality, morbidity and clinical care in a referral neonatal intensive care unit in Haiti.

BACKGROUND: Neonatal mortality rates in Haiti are among the highest in the Western hemisphere. Few mothers deliver with a skilled birth attendant present, and there is a significant lack of pediatricians. The neonatal intensive care unit (NICU) at St. Damien Pediatric Hospital, a national referral center, is one of only five neonatology departments in Haiti. In order to target limited resources toward improving outcomes, this study seeks to describe clinical care in the St. Damien NICU. METHODS: A retrospective medical record review was performed on available medical records on all admissions to the NICU between April 2016 and April 2017. RESULTS: 220 neonates were admitted to the NICU within the study epoch. The mortality rate was 14.5%. Death was associated with a maternal diagnosis of hypertension (p = 0.03) and neonatal diagnoses of lower gestational age (p<0.0001), lower birth weight (p<0.0001), prematurity (p = 0.002), RDS p = 0.01), sepsis (p<0.0001) and kernicterus (p = 0.04). The most common diagnoses were sepsis, chorioamnionitis, respiratory distress syndrome, jaundice, prematurity and perinatal asphyxia. CONCLUSIONS: This study demonstrates that preterm birth, sepsis, RDS and kernicterus are key contributors to neonatal mortality in a Haitian national pediatric referral center NICU and as such are promising interventional targets for reducing the neonatal mortality rate in Haiti.

Unraveling Diagnostic Uncertainty Surrounding Lyme Disease in Children with Neuropsychiatric Illness.

Lyme disease is endemic in parts of the United States, including New England, the Atlantic seaboard, and Great Lakes region. The presentation has various manifestations, many of which can mimic psychiatric diseases in children. Distinguishing manifestations of Lyme disease from those of psychiatric illnesses is complicated by inexact diagnostic tests and misuse of these tests when they are not clinically indicated. This article aims to describe manifestations of Lyme disease in children with an emphasis on Lyme neuroborreliosis. Clinical scenarios will be presented and discussed. Finally, recommendations for clinical psychiatrists who encounter children with possible Lyme disease are presented.

Percepção de risco e comportamentos de proteção face à covid-19 em estudantes do ensino superior: o papel mediador do medo / Percepción del riesgo y conductas protectoras frente al covid-19 en estudiantes de enseñanza superior: el papel mediador del miedo / Risk Perception and Protective Behaviors Against covid-19 in Higher Education Students: The Mediating Role of Fea

O estudo tem como objetivo descrever os comportamentos de proteção adotados por estudantes portugue-ses do ensino superior durante a pandemia e analisar a sua relação com a percepção de risco e o papel mediador do medo face à covid-19. Participaram 335 estu-dantes com idades entre os 18 e os 29 anos (m= 21.42; dp= 2.43). Os participantes preencheram um inquérito sobre os comportamentos de proteção (i.e., preventi-vos e de evitamento), a percepção de risco e o medo face à covid-19. Os resultados demonstraram que os comportamentos preventivos mais utilizados foram a lavagem/desinfecção das mãos ao longo do dia e o uso de máscara na via pública ou espaços exteriores. Os comportamentos de evitamento mais adotados foram o de evitar locais com aglomeração e os convívios presenciais com colegas/amigos. Verificouse uma as-sociação positiva entre os comportamentos de proteção, a percepção de gravidade e o medo face à covid-19. O medo face à covid-19 foi mediador da relação entre a percepção de gravidade e os comportamentos preventivos (c' = .26, ic 95% [.11; .44]) e de evitamento (c' = .28, ic 95% [.12; .50]). Os resultados são discutidos aten-dendo ao papel da percepção de risco e do medo nas respostas comportamentais dos jovens, num contexto de pandemia, sendo apresentadas implicações práticas e sugestões para estudos futuros.

El estudio tiene como objetivo describir las conductas protectoras adoptadas por los estudiantes portugueses de educación superior durante la pandemia, y analizar su relación con la percepción de riesgo y el papel mediador del miedo al covid-19. Participaron en el estudio 335 estudiantes de entre 18 y 29 años (m = 21.42; ds = 2.43). Los participantes completaron una encuesta sobre conductas protectoras (es decir, preventivas y de evitación), percepción de riesgo y miedo al covid-19. Los resultados mostraron que las conductas preventivas más utilizadas fueron el lavado/desinfección de manos a lo largo del día y el uso de mascarilla en la vía pública o al aire libre. Los comportamientos de evitación más adoptados fueron evadir lugares con reuniones e interacciones cara a cara con compañeros/amigos. Hubo una correlación positiva entre las conductas protectoras, la percepción de seriedad y el miedo al covid-19. También se encontró que el miedo al covid-19 medió la relación entre la percepción de severidad y las conductas preventivas (c' = .26, ic 95% [.11; .44]) y de evitación (c' = .28, ic 95% [.12; .50]). Los resultados se discuten considerando el papel de la percepción del riesgo y el miedo en las respuestas conductuales de los jóvenes en un contexto pandémico, así mismo se presentan impli-caciones prácticas y sugerencias para estudios futuros.

The study aims to describe the protective behaviors adopted by Portuguese higher education students in during the and to analyze their relationship with the perception of risk and the mediating role of fear of covid-19. A total of 335 students aged be-tween 18 and 29 participated in the study (m= 21.42; sd = 2.43). Participants completed a survey on protective (i.e., preventive and avoidance) behaviors, risk perception, and fear of covid-19. The results showed that the most used preventive behaviors were hand washing/disinfection throughout the day and using masks in public streets or outdoor spaces. The most adopted avoidance behaviors were avoiding crowded places and face-to-face interactions with colleagues/friends. There was a positive correlation between pro-tective behaviors, the perception of severity, and fear of covid-19. Fear of covid-19 mediated the relation between the perception of severity and both preventive (c' = .26, ic 95% [.11; .44]) and avoidance (c' = .28, ic95% [.12; .50]) behaviors. The results are discussed considering the role of risk perception and fear in the behavioral responses of young people in a pandemic context while presenting practical implications and suggestions for future studies.

Would Parents Consent to a Comparative Effectiveness Trial of Oral Doxycycline Versus Intravenous Ceftriaxone for the Treatment of Children with Lyme Meningitis?

Children with Lyme meningitis are often treated with intravenous ceftriaxone, although oral doxycycline may be effective. Parents were surveyed after observing a video describing a hypothetical Lyme meningitis treatment trial. Eighty-four of 102 (82%) would consent to their child participating. Parents would accept 2 additional days of symptoms (noninferiority margin) with doxycycline even if ceftriaxone hastened symptom resolution.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda.

BACKGROUND: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

A Sustained Partnership between a Haitian Children's Hospital and North American Academic Medical Centers.

Global health initiatives from academic medical centers have rapidly proliferated over the last decade. This paper endeavors to describe our 5-year experience as an academic medical collaborative supporting healthcare delivery, medical training, and research at Hôpital Saint Damien-Nos Petits Frères et Soeurs, the only freestanding children's hospital in Haiti. Descriptions of the history and current activities of our academic medical collaborative, its partnership and communication structure, its evolution to fill the expressed needs of our host site, its funding mechanisms, and its challenges and opportunities for the future are included.

Use of Intermittent vs Continuous Pulse Oximetry for Nonhypoxemic Infants and Young Children Hospitalized for Bronchiolitis: A Randomized Clinical Trial.

IMPORTANCE: Clinical practice guidelines for managing infants and children hospitalized for bronchiolitis recommend only obtaining intermittent or "spot check" pulse oximetry readings for those who show clinical improvement. The effect of such monitoring is currently unknown. OBJECTIVE: To determine the effect of intermittent vs continuous pulse oximetry monitoring on hospital length of stay among nonhypoxemic infants and young children hospitalized for bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS: Randomized, parallel-group, superiority clinical trial of otherwise healthy infants and children 2 years of age or younger hospitalized for bronchiolitis during the period from 2009 to 2014 at 1 of 4 children's hospitals in the United States. Parents or guardians were blinded to allocation assignment until informed consent was obtained; study personnel and outcome assessors were not. INTERVENTIONS: Patients were randomly assigned to undergo continuous or intermittent pulse oximetry monitoring (ie, pulse oximetry measurements were obtained along with a scheduled check of vital signs or for clinical suspicion of deterioration) during hospitalization when oxygen saturation levels were 90% or higher. MAIN OUTCOMES AND MEASURES: Length of hospital stay was the primary outcome. Secondary outcome measures included duration of supplemental oxygen use and rate of escalation of care (defined as transfer to an intensive care unit). RESULTS: A total of 449 infants and young children were screened for inclusion; 288 infants and young children were excluded, resulting in 161 patients who were enrolled in the study (80 patients underwent continuous monitoring, and 81 patients intermittent). The mean length of stay did not differ based on pulse oximetry monitoring strategy (48.9 hours [95% CI, 41.3-56.5 hours] for continuous monitoring vs 46.2 hours [95% CI, 39.1-53.3 hours] for intermittent monitoring; P = .77). The rates of escalation of care and duration of supplemental oxygen use did not differ between groups. CONCLUSIONS AND RELEVANCE: Intermittent pulse oximetry monitoring of nonhypoxemic patients with bronchiolitis did not shorten hospital length of stay and was not associated with any difference in rate of escalation of care or use of diagnostic or therapeutic measures. Our results suggest that intermittent pulse oximetry monitoring can be routinely considered in the management of infants and children hospitalized for bronchiolitis who show clinical improvement. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01014910.

HIV Testing for At-Risk Adolescents at Rhode Island Hospital.

Early detection of HIV has great potential to reduce transmission, especially when newly diagnosed individuals are treated early. Early treatment and suppression of viral loads is known to effectively attenuate HIV transmission. However, little is known about whether persons at high risk for HIV are being appropriately tested during healthcare encounters according to national guidelines. Specifically, the at-risk adolescent population may be under tested and are not routinely monitored by state-level surveillance system. This study reviewed HIV testing rates for at-risk adolescents from 2005-2012 at the main tertiary care and pediatric center in Rhode Island. While the absolute number of HIV tests for at-risk adolescents continued to increase, the HIV testing rates for this population decreased during the seven year period. Increasing awareness of HIV testing for patients, their families, and physicians may improve the HIV testing rate among at-risk adolescents in Rhode Island.

Evaluating the use of blood cultures in the management of children hospitalized for community-acquired pneumonia.

BACKGROUND: Blood cultures are often recommended for the evaluation of community-acquired pneumonia (CAP). However, institutions vary in their use of blood cultures, and blood cultures have unclear utility in CAP management in hospitalized children. OBJECTIVE: To identify clinical factors associated with obtaining blood cultures in children hospitalized with CAP, and to estimate the association between blood culture obtainment and hospital length of stay (LOS). METHODS: We performed a multicenter retrospective cohort study of children admitted with a diagnosis of CAP to any of four pediatric hospitals in the United States from January 1, 2011-December 31, 2012. Demographics, medical history, diagnostic testing, and clinical outcomes were abstracted via manual chart review. Multivariable logistic regression evaluated patient and clinical factors for associations with obtaining blood cultures. Propensity score-matched Kaplan-Meier analysis compared patients with and without blood cultures for hospital LOS. RESULTS: Six hundred fourteen charts met inclusion criteria; 390 children had blood cultures obtained. Of children with blood cultures, six (1.5%) were positive for a pathogen and nine (2.3%) grew a contaminant. Factors associated with blood culture obtainment included presenting with symptoms of systemic inflammatory response syndrome (OR 1.78, 95% CI 1.10-2.89), receiving intravenous hydration (OR 3.94, 95% CI 3.22-4.83), receiving antibiotics before admission (OR 1.49, 95% CI 1.17-1.89), hospital admission from the ED (OR 1.65, 95% CI 1.05-2.60), and having health insurance (OR 0.42, 95% CI 0.30-0.60). In propensity score-matched analysis, patients with blood cultures had median 0.8 days longer LOS (2.0 vs 1.2 days, P < .0001) without increased odds of readmission (OR 0.94, 95% CI 0.45-1.97) or death (P = .25). CONCLUSIONS: Obtaining blood cultures in children hospitalized with CAP rarely identifies a causative pathogen and is associated with increased LOS. Our results highlight the need to refine the role of obtaining blood cultures in children hospitalized with CAP.

Building international collaborations from the ground up: Brown University partnerships in Haiti and Ukraine.

The world is becoming more interconnected with a need for a global approach to healthcare. Brown University has remained a leader in global health through clinical service, education, cutting edge research and dedication to the development of sustainable global partnerships. We describe two programs from the ground up in Haiti and Ukraine, and the important lessons learned in their development. The path towards the development of global health programs in Ukraine and Haiti both illustrate that although circumstances may vary between global health programs, the recipe for successful collaboration is the same: identifying specific needs, developing strong and sustained partnerships, and addressing barriers by crafting effective solutions to ongoing challenges.

Needle length for immunization of early adolescents as determined by ultrasound.

OBJECTIVE: To determine the appropriate needle length for intramuscular injection of vaccines to early adolescents by measuring muscle depth at the deltoid injection site. METHODS: Students from Nassau County, New York, and patients attending an adolescent clinic were invited to participate. Height, weight, and arm circumference were measured. BMI percentiles were obtained. Depths of muscle and bone underlying the deltoid injection site were measured by using ultrasonography while the deltoid area was bunched or flattened. A sufficiently long needle length was defined as greater than or equal to the skin-to-muscle depth plus 5 mm (based on measurement, no needle used). Too long was considered greater than or equal to skin-to-bone depth. RESULTS: The age range of the 141 subjects was 11 to 15 years. Fifty-five percent were female. Twenty-six percent weighed <40 kg, and 20% were between 60 and 108 kg. The mean and median BMI percentiles were 58th and 62th, respectively, with 6% of the subjects at <10th percentile and 28% of subjects at >85th percentile. Using the bunch technique, we found that a 25-mm (1-in) needle is acceptable in 86% of subjects; in the subgroup of >or=60 kg, it is acceptable in 100% of subjects. A 16-mm (-in) needle is acceptable in 88%; in the subgroup of <60 kg, it is acceptable in 98% of subjects. Using the flatten technique, a 25-mm needle is acceptable in 39%; in the subgroup of >or=60 kg, it is acceptable in 93% of subjects. A 16-mm needle is acceptable in 92%; in the subgroup of <60 kg, it is acceptable in 96% of subjects. CONCLUSIONS: For intramuscular immunization of early adolescents, a 16-mm needle is appropriate for those weighing <60 kg, and a 25-mm needle is appropriate for those weighing 60 to 70 kg, using either technique.