Total body skeletal muscle mass estimated by magnetic resonance imaging and creatine (methyl-d3 ) dilution in athletes.

Creatine dilution (D3 -cr) is a technique for estimating total skeletal muscle mass (SMM) with practical utility, but has not been applied in athletic populations where body composition may differ to that in the normal population. This study aimed to assess the agreement between SMM derived from both D3 -cr and that obtained from whole-body magnetic resonance imaging (MRI) in 15 male and 5 female national level kayakers (stature: 182.0 ± 13.1 and 170.0 ± 9.0 cm; body mass: 80.6 ± 9.9 and 66.4 ± 6.0 kg; V̇O2 peak: 56.5 ± 7.0 and 49.6 ± 4.4 mL kg-1  min-1 , mean ± SD). SMM was determined following 60 mg of dosed D3 -cr and analysis of expelled urine collected on four subsequent days for creatine, creatinine, D3 -cr, and D3 -creatinine using liquid chromatography/mass spectroscopy. SMM was then estimated by assuming a creatine pool size of 4.3 g/kg. During the same time period, a whole-body MRI was undertaken to derive SMM from the analysis of multiple slices taken across the body. A strong positive correlation (F = 74.32; R = 0.90; P < .0001) between the two methods was observed, but the D3 -cr SMM was found to be significantly higher (43.3 ± 6.8 kg) when compared with MRI (36.3 ± 5.8 kg, P < .0001). However, the difference between the methods was removed when a higher intramuscular creatine pool (5.1 g/kg) was assumed. These data show that D3 -cr has potential utility in athletes, as referenced against MRI, but show that assumptions regarding creatine pool size need to be carefully considered.

Interobserver reliability of attending physicians and bedside nurses when using an inpatient paediatric respiratory score.

AIMS AND OBJECTIVES: This study aimed to determine the interobserver reliability between bedside nurses and attending physicians for a paediatric respiratory score as part of an asthma Integrated Care Pathway implementation. BACKGROUND: An Integrated Care Pathway is one approach to improving quality of care for children hospitalised with asthma. Prior to implementation of the integrated care pathway, it was necessary to train nursing staff on the use of a respiratory assessment tool and to evaluate the interobserver reliability use of this tool. DESIGN: Prospective study using a convenience sample of children hospitalised for a respiratory illness in an academic medical centre. METHODS: The respiratory assessment used was the Paediatric Asthma Score. Bedside nurse-attending physician (27 different RNs and three attending paediatric hospitalists) pairs performed 71 simultaneous patient assessments on 20 patients. Intraclass correlation coefficient and kappa statistics were used to assess interobserver reliability. RESULTS: The overall intraclass correlation coefficient was nearly perfect where κ = 0·95, 95% CI (0·92, 0·97) and overall kappa for reliability based on clinically relevant score breakpoints was also high with κ = 0·82, 95% CI (0·75, 0·90). The majority of subgroup analyses revealed substantial to almost perfect agreement across a variety of diagnoses, age ranges, and individual score components. CONCLUSIONS: Bedside nurses, with support and training from attending physicians, can perform respiratory assessments that agree almost perfectly with those of attending physicians. RELEVANCE TO CLINICAL PRACTICE: The use of an Integrated Care Pathway allows for optimal interprofessional collaboration between bedside nurses and attending physicians.

Patient Safety and Quality Improvement: Reducing Risk of Harm.

Most medical errors and preventable adverse events represent failures of complex systems. Pediatric clinicians must ensure a safe environment for health-care delivery to children. To do so, they must recognize risk factors for errors and adverse events; ensure effective communication with patients, parents, and colleagues; heighten situation awareness; develop high-functioning, high-reliability teams; implement and employ technology carefully; and provide integrated, ongoing education to trainees.

Patient safety and quality improvement: an overview of QI.

It is important for pediatric providers to be involved in quality improvement (QI) activities to improve children's health outcomes.• The Model for Improvement asks several key questions related to a process, then uses Plan-Do-Study-Act(PDSA) cycles to implement, test, and spread changes.• Lean and Six Sigma methodologies can improve quality by increasing workflow efficiency and decreasing variation.• Root cause analysis (RCA) is a retrospective quality tool that helps determine factors contributing to errors and adverse events, so that improvements can be implemented.• Failure modes and effects analysis (FMEA) isa prospective quality tool that anticipates system vulnerabilities and helps develop risk reduction strategies.• Evidence-based interventions, such as best-practice guidelines, promote standardization and reduce errors and adverse events, especially in high-risk health-care settings.• Team training can improve communication and situational awareness to create a safer health-care environment.

Guidance for Structuring a Pediatric Intermediate Care Unit.

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

Improving the Timing of Laboratory Studies in Hospitalized Children: A Quality Improvement Study.

OBJECTIVES: For hospitalized children and their families, laboratory study collection at night and in the early morning interrupts sleep and increases the stress of a hospitalization. To change this practice, our quality improvement (QI) study developed a rounding checklist aimed at increasing the percentage of routine laboratory studies ordered for and collected after 7 am. METHODS: Our QI study was conducted on the pediatric hospital medicine service at a single-site urban children's hospital over 28 months. Medical records from 420 randomly selected pediatric inpatients were abstracted, and 5 plan-do-study-act cycles were implemented during the intervention. Outcome measures included the percentage of routine laboratory studies ordered for and collected after 7 am. The process measure was use of the rounding checklist. Run charts were used for analysis. RESULTS: The percentage of laboratory studies ordered for after 7 am increased from a baseline median of 25.8% to a postintervention median of 75.0%, exceeding our goal of 50% and revealing special cause variation. In addition, the percentage of laboratory studies collected after 7 am increased from a baseline median of 37.1% to 76.4% post intervention, with special cause variation observed. CONCLUSIONS: By implementing a rounding checklist, our QI study successfully increased the percentage of laboratory studies ordered for and collected after 7 am and could serve as a model for other health care systems to impact provider ordering practices and behavior. In future initiatives, investigators should evaluate the effects of similar interventions on caregiver and provider perceptions of patient- and family-centeredness, satisfaction, and the quality of patient care.

The Value of Family Advisors as Coleaders in Pediatric Quality Improvement Efforts: A Qualitative Theme Analysis.

Engaging family advisors in pediatric quality improvement (QI) efforts is well-studied in intensive care but less understood in other settings. The purpose of this study was to assess the perceived impact of including a family advisor as a colead on a QI initiative that successfully improved the family-centered timing of routine morning blood tests performed on pediatric inpatients. Five structured written reflections from core QI team members were analyzed using inductive thematic analysis and 3 major themes were identified. The first found that a family advisor's presence from the beginning of a QI initiative helps inform project design. The second determined that family partners working with residents fostered a better shared understanding of the role of trainees and caregivers in improving the quality of care. The third found that a family partner is an effective change agent to enact practice improvement, support professional development, and enhance resident education. Our qualitative analysis showed that engaging a family advisor as a colead influenced the design, implementation, and post-intervention impact of the initiative and improved family-centered outcomes.

Infantile gastroesophageal reflux in a hospital setting.

BACKGROUND: Gastroesophageal reflux is a common diagnosis in infants. Yet, there is no information on the demographics of those hospitalized with reflux. The aim of this study is to describe the demographics of children with gastroesophageal reflux discharged from the hospital during the first two years of life. METHODS: Retrospective chart review of children aged 0-2 years discharged between January 1, 1995 and December 31, 1999 with a diagnosis of reflux documented in their hospital chart prior to 12 months of age. RESULTS: Reflux was the seventh most common reason for hospitalization. About 50% of subjects with reflux had multiple hospitalizations. Of the 1,096 infants diagnosed with reflux about half were born prematurely. Reflux was the primary diagnosis for 21% of all infants; 10% of those born prematurely. The average length of stay for the subjects was longer than the hospital average. African Americans, 2.4% of the population, accounted for 29% of discharges. Caucasians, 86% of the population, were 66% of discharges. 21.8% of African Americans and 68.3% of Caucasians were diagnosed with reflux. 35% of mothers smoked, 27% worked and 48% had public insurance, compared to 22.2%, 57%, and 24% respectively of females in the general population. CONCLUSION: Reflux is a common discharge diagnosis. Children who have primary reflux have longer than average hospital stays. About half had multiple admissions. Mothers of children with reflux are more likely to be less educated, receive public insurance, smoke, and be unemployed than the general female population in Western New York. Although African American children were disproportionately hospitalized, they were less likely to be diagnosed with reflux.

Association between resource utilization and patient satisfaction at a tertiary care medical center.

BACKGROUND: The Centers for Medicare and Medicaid Services has emphasized patient satisfaction as a means by which hospitals should be compared and as a component of financial reimbursement. We sought to identify whether resource utilization is associated with patient satisfaction ratings. DESIGN: This was a retrospective, cohort study over a 27-month period from January 2012 to April 2014 of adult respondents (n = 10,007) to the Hospital Consumer Assessment of Healthcare Providers and Systems survey at a tertiary care medical center. For each returned survey, we developed a resource intensity score related to the corresponding hospitalization. We calculated a raw satisfaction rating (RSR) for each returned survey. Multivariable logistic regression was used to determine the association between resource intensity and top decile RSRs, using those with the lowest resource intensity as the reference group. RESULTS: Adjusting for age, gender, insurance payer, severity of illness, and clinical service, patients in higher resource intensity groups were more likely to assign top decile RSRs than the lowest resource intensity group ("moderate" [adjusted odds ratio {aOR}: 1.42, 95% confidence interval {CI}: 1.11-1.83], "major" [aOR: 1.56, 95% CI: 1.22-2.01], and "extreme" [aOR: 2.29, 95% CI: 1.8-2.92]). CONCLUSIONS: Resource utilization may be positively associated with patient satisfaction. These data suggest that hospitals with higher per-patient expenditures may receive higher ratings, which could result in hospitals with higher per-patient resource utilization appearing more attractive to healthcare consumers. Journal of Hospital Medicine 2016;11:785-791. © 2016 Society of Hospital Medicine.

Proportional Distribution of Patient Satisfaction Scores by Clinical Service: The PRIME Model.

The Proportional Responsibility for Integrated Metrics by Encounter (PRIME) model is a novel means of allocating patient experience scores based on the proportion of each physician's involvement in care. Secondary analysis was performed on Hospital Consumer Assessment of Healthcare Providers and Systems surveys from a tertiary care academic institution. The PRIME model was used to calculate specialty-level scores based on encounters during a hospitalization. Standard and PRIME scores for services with the most inpatient encounters were calculated. Hospital medicine had the most discharges and encounters. The standard model generated a score of 74.6, while the PRIME model yielded a score of 74.9. The standard model could not generate a score for anesthesiology due to the lack of returned surveys, but the PRIME model yielded a score of 84.2. The PRIME model provides a more equitable method for distributing satisfaction scores and can generate scores for specialties that the standard model cannot.

Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care.

BACKGROUND: Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change. METHODS: This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011-September 30, 2011) and after (July 1, 2012-September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis. RESULTS: We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P < 0.001). We found no significant difference in LOS, the number of changes to initial resident antibiotic choice, standard of care, or RRTs called within the first 24 hours of admission. CONCLUSION: Removing mandated attending input in decision making for PHM admissions significantly decreased time to inpatient resident admission orders without a change in measurable clinical outcomes.

Total body skeletal muscle mass: estimation by creatine (methyl-d3) dilution in humans.

Current methods for clinical estimation of total body skeletal muscle mass have significant limitations. We tested the hypothesis that creatine (methyl-d3) dilution (D3-creatine) measured by enrichment of urine D3-creatinine reveals total body creatine pool size, providing an accurate estimate of total body skeletal muscle mass. Healthy subjects with different muscle masses [n = 35: 20 men (19-30 yr, 70-84 yr), 15 postmenopausal women (51-62 yr, 70-84 yr)] were housed for 5 days. Optimal tracer dose was explored with single oral doses of 30, 60, or 100 mg D3-creatine given on day 1. Serial plasma samples were collected for D3-creatine pharmacokinetics. All urine was collected through day 5. Creatine and creatinine (deuterated and unlabeled) were measured by liquid chromatography mass spectrometry. Total body creatine pool size and muscle mass were calculated from D3-creatinine enrichment in urine. Muscle mass was also measured by magnetic resonance imaging (MRI), dual-energy x-ray absorptiometry (DXA), and traditional 24-h urine creatinine. D3-creatine was rapidly absorbed and cleared with variable urinary excretion. Isotopic steady-state of D3-creatinine enrichment in the urine was achieved by 30.7 ± 11.2 h. Mean steady-state enrichment in urine provided muscle mass estimates that correlated well with MRI estimates for all subjects (r = 0.868, P < 0.0001), with less bias compared with lean body mass assessment by DXA, which overestimated muscle mass compared with MRI. The dilution of an oral D3-creatine dose determined by urine D3-creatinine enrichment provides an estimate of total body muscle mass strongly correlated with estimates from serial MRI with less bias than total lean body mass assessment by DXA.

Longitudinal changes in total body creatine pool size and skeletal muscle mass using the D3-creatine dilution method.

BACKGROUND: We recently validated in cross-sectional studies a new method to determine total body creatine pool size and skeletal muscle mass based on D3-creatine dilution from an oral dose and detection of urinary creatinine enrichment by isotope ratio mass spectrometry (IRMS). Routine clinical use of the method in aging and disease will require repeated application of the method, with a more widely available technology than IRMS, to enable determination of change in skeletal muscle mass in longitudinal studies. We therefore adapted the method to liquid chromatography-tandem mass spectrometry (LC-MS/MS) technology, and sought to establish proof of concept for the repeated application of the method in a longitudinal study. Because the turnover of creatine is slow, it was also critical to determine the impact of background enrichment from an initial dose of oral D3-creatine on subsequent, longitudinal measurements of change in muscle mass. METHODS: Rats were given an oral tracer dose of D3-creatine (1.0 mg/kg body weight) at 10 and 17 weeks of age. LC-MS/MS was used to determine urinary D3-creatine, and urinary D3-creatinine enrichment, at time intervals after D3-creatine administration. Total body creatine pool size was calculated from urinary D3-creatinine enrichment at isotopic steady state 72 h after administration of D3-creatine tracer. RESULTS: At 10 weeks of age, rat lean body mass (LBM) measured by quantitative magnetic resonance correlated with creatine pool size (r = 0.92, P = 0.0002). Over the next 7 weeks, the decline in urinary D3-creatinine enrichment was slow and linear, with a rate constant of 2.73 ± 0.06 %/day. Subtracting background urinary D3-creatinine enrichment from the elevated enrichment following a second dose of D3-creatine at 17 weeks permitted repeat calculations of creatine pool size. As at 10 weeks, 17-week LBM correlated with creatine pool size (r = 0.98, P <0.0001). In addition, the change in creatine pool size was correlated with the change in LBM during the 7 weeks of rat growth between measurements (r = 0.96, P <0.0001). CONCLUSION: The LC-MS/MS-based D3-creatine dilution method can be applied repeatedly to measure total body creatine skeletal muscle mass change in longitudinal study.

Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.

BACKGROUND: Medication management is a complex, multifaceted system. Prescribing errors occur upstream in the process, and as such, their effects can be perpetuated, and sometimes even exacerbated, in subsequent steps. These errors place patients at risk of adverse drug events. Children, especially young infants, are at particular risk because of their size, unique physiology, and immature ability to metabolize drugs. OBJECTIVE: The purpose of this study was to reduce the risk of harm to children resulting from prescribing errors. METHODS: We sequentially implemented patient safety initiatives over a 1-year time frame at a pediatric tertiary care academic facility. The initiatives included an educational Web site with competency examination, distribution of a personal digital assistant-based standardized dosing reference, a zero-tolerance policy for incomplete or incorrect medication orders, prescriber performance feedback, and presentation of outcome data at citywide grand rounds. A total of 8718 orders were collected and analyzed to assess the impact of these initiatives. RESULTS: The absolute risk reduction from prescribing errors was 38 per 100 orders, with a relative risk reduction of 49%. Web-based education with point-of-care drug references and a zero-tolerance policy for incomplete or incorrect orders were most effective in decreasing potential adverse drug events. Documentation of appropriate weight-based dosing and indication for therapy increased by 24% and 42%, respectively. CONCLUSIONS: Process-improvement initiatives focusing on prescriber education and behavior modification can reduce the risk of harm to pediatric patients from prescribing errors.

Synthesis of a pondaplin dimer and trimer. Aromatic interactions in novel macrocycles.

Synthetic challenges in the use of an oxabicyclo[2.2.2]octenone moiety as a masked arene for the synthesis of pondaplin are disclosed. During the course of a study of the Heck reaction as a tool for macrocyclization to provide strained paracyclophanes, novel macrocycles displaying intra- and intermolecular aromatic interactions have been synthesized. The geometry of these interactions is compared to recent computational literature data.

Phenylacetylglycine, a putative biomarker of phospholipidosis: its origins and relevance to phospholipid accumulation using amiodarone treated rats as a model.

Amiodarone was given to male Sprague-Dawley rats at a dose of 150 mg kg(-1) day(-1) for 7 consecutive days to induce phospholipidosis in the lungs of treated rats. Amiodarone was given alone or concurrently with phenobarbitone. Animals given amiodarone had raised total phospholipid in serum, lung and lymphocytes, and elevated lyso(bis)phosphatidic acid (LBPA) in all tissues. Urinary and plasma phenylacetylglycine (PAG) and hepatic portal:aortal phenylacetate (PA) ratio were increased, whereas hepatic phenylalanine hydroxylase (PAH) activity and plasma phenylalanine:tyrosine ratio were not affected. Phenobarbitone treatment increased hepatic total P450 content and induced 7-pentoxyresorufin O-dealkylatian (PROD) activity, as expected, but had no effect on any other biochemical parameter. Plasma amiodarone concentration was reduced in rats co-administered both drugs and phospholipid accumulation in target tissues was attenuated compared with rats treated with amiodarone alone. However, phenobarbitone co-administration failed to alter the magnitude of response with regards to urinary PAG excretion and plasma concentration of its precursors after amiodarone treatment. Increased intestinal absorption of PAG precursors probably resulted in the raised urinary PAG after amiodarone treatment. Urinary PAG correlated weakly with serum, lymphocyte and lung phospholipids. However, urinary PAG excretion was similar in rats dosed solely with amiodarone or in combination with phenobarbitone, despite the fact that the degree of phospholipid accumulation was far less in rats given the combined treatment. Nevertheless, urinary PAG was raised only in animals exhibiting abnormal phospholipid accumulation in target tissues and may thus be useful as a surrogate biomarker for phospholipidosis.

Chemical defense in ascidians of the didemnidae family.

Fluorescent analogues (DB1 and TA1) of the secondary metabolites didemnin B (DB) and tamandarin A (TA) were synthesized to investigate the potential chemical defense mechanisms of tunicates in the family Didemnidae. These compounds were found to alter predator-prey relations. Five species of freshwater fish and one marine fish, the damselfish Amphiprion ocellaris, were acclimated to a diet of mosquito larvae. Fish showed an immediate, negative reaction to mosquito larvae treated with >/=5 ng of DB1 or TA1, with consumption of larvae resulting in regurgitation. Both freshwater and marine fish learned to avoid tainted prey by associating species of larvae with "distaste". Distaste for a given organism also arose when depsipeptides DB1 or TA1 were transferred to the fish from the surrounding medium. Fluorescence microscopy in fish indicated that a similar processing and localization followed ingestion and absorption of DB1 or TA1. Fluorescent labeling of DB or TA provided an ideal tool to conduct short-term studies of predator-prey relationships between fish and marine invertebrate larvae.