Utility of a Benchmarking Report for Balancing Infection Prevention and Antimicrobial Stewardship in Children with Complicated Appendicitis.

OBJECTIVE: To develop a severity-adjusted, hospital-level benchmarking comparative performance report for postoperative organ space infection and antibiotic utilization in children with complicated appendicitis. BACKGROUND: No benchmarking data exist to aid hospitals in identifying and prioritizing opportunities for infection prevention or antimicrobial stewardship in children with complicated appendicitis. METHODS: This was a multicenter cohort study using NSQIP-Pediatric data from 16 hospitals participating in a regional research consortium, augmented with antibiotic utilization data obtained through supplemental chart review. Children with complicated appendicitis who underwent appendectomy from 07/01/2015 to 06/30/2020 were included. Thirty-day postoperative OSI rates and cumulative antibiotic utilization were compared between hospitals using observed-to-expected (O/E) ratios after adjusting for disease severity using mixed effects models. Hospitals were considered outliers if the 95% confidence interval for O/E ratios did not include 1.0. RESULTS: 1790 patients were included. Overall, the OSI rate was 15.6% (hospital range: 2.6-39.4%) and median cumulative antibiotic utilization was 9.0 days (range: 3.0-13.0). Across hospitals, adjusted O/E ratios ranged 5.7-fold for OSI (0.49-2.80, P=0.03) and 2.4-fold for antibiotic utilization (0.59-1.45, P<0.01). Three (19%) hospitals were outliers for OSI (1 high and 2 low performers), and eight (50%) were outliers for antibiotic utilization (5 high and 3 low utilizers). Ten (63%) hospitals were identified as outliers in one or both measures. CONCLUSIONS: A comparative performance benchmarking report may help hospitals identify and prioritize quality improvement opportunities for infection prevention and antimicrobial stewardship, as well as identify exemplar performers for dissemination of best practices.

Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis.

OBJECTIVE: To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. BACKGROUND: Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision. METHODS: This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. RESULTS: A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. CONCLUSIONS: Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.

Use of Antipseudomonal Antibiotics is not Associated with Lower Rates of Postoperative Drainage Procedures or More Favorable Culture Profiles in Children with Complicated Appendicitis: Results from a Multicenter Regional Research Consortium.

OBJECTIVE: To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the two most common antibiotic regimens with and without antipseudomonal activity (piperacillin-tazobactam [PT] and ceftriaxone with metronidazole [CM]). SUMMARY OF BACKGROUND DATA: Variation in use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes. METHODS: Retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed effects regression to adjust for clustering after propensity matching on measures of disease severity. RESULTS: 1002 children met criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall (PT: 11.8%, CM: 12.1%; OR 1.44 [OR:0.71-2.94]) and higher rates of drainage associated with growth of any organism (PT: 7.7%, CM: 4.6%; OR 2.41 [95%CI:1.08-5.39]) and Escherichia coli (PT: 4.6%, CM: 1.8%; OR 3.42 [95%CI:1.07-10.92]) compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms (PT: 2.6%, CM: 1.5%; OR 3.81 [95%CI:0.96-15.08]) and Pseudomonas (PT: 1.0%, CM: 1.3%; OR 3.42 [95%CI:0.55-21.28]). CONCLUSIONS AND RELEVANCE: Use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis.

"The Future of Nursing: Accelerating gains made to address the continuum of substance use".

PURPOSE: Guided by four key messages from the decade-old Institute of Medicine (IOM) report, "The Future of Nursing," this paper highlights the progress made by the nursing profession in addressing substance use and its related disorders and offers recommendations to sustain and advance efforts to enhance care for persons who use substances, one of the most stigmatized and vulnerable populations. RESULTS: Patterns of substance use have shifted over the past 10 years, but the associated harms remain consequential. As awareness of the continuum of substance use has expanded, the care of persons with substance use has also expanded, from the domains of psychiatric-mental health and addictions nursing specialties to the mainstream of nursing. Now, greater efforts are being undertaken to identify and intervene with persons at risk for and experiencing substance use disorders. Nurses have advanced the knowledge and skills necessary for substance-related nursing care including education and training, leadership, care innovations, and workforce expansion and can drive efforts to increase public knowledge about the health risks associated with substance use. Recommendations aligned with each of the four IOM key messages are offered. CONCLUSIONS: As a profession, nursing has a responsibility to expand the progress made in addressing substance use - from prevention and early intervention to tertiary care. Nurses at all levels of education and practice are in key positions to carry out the recommendations herein to accelerate the changes needed to provide high quality care for persons impacted by substance use.

Experiences and outcomes of nurses referred to a peer health assistance program: Recommendations for nursing management.

AIM: To provide recommendations for nursing management based on the experiences of current and former nurses who were served by a peer health assistance program (PHAP). BACKGROUND: Providing help for nurses with impaired practice is critical to their health and well-being, assuring patient safety and public trust, as well as returning competent nurses to the healthcare workforce. METHODS: Nurses (n = 268) who were current clients or former clients of a PHAP were surveyed about their experiences. RESULTS: Nearly half of nurses were referred by the board of nursing with 69% reporting the referral was due to substance use, alcohol being the most common. Most (62%) did not believe that their substance use affected their practice yet relayed that recognition of their emotional or physical condition could have led to earlier identification. Key barriers to seeking assistance were fear and embarrassment, along with concerns about losing their nursing license. CONCLUSIONS: Nurses in management are in key roles to identify and intervene with nurses who are at risk for impaired practice. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses in management and nurse colleagues would benefit from workplace education on the warning signs of impaired nursing practice and how to address it.

Follicular thyroid carcinoma metastasis to the facial skeleton: a systematic review.

BACKGROUND: Follicular thyroid carcinoma (FTC) metastasis to the facial skeleton is exceedingly rare. A case of FTC metastasizing to the mandible is presented and a systematic review of the literature describing thyroid metastasis to the facial skeleton is performed. CASE PRESENTATION: A 73-year-old female presented with metastatic FTC to the mandible and underwent total thyroidectomy, segmental mandibulectomy, bone impacted fibular free flap reconstruction, and adjuvant radioactive iodine treatment. The PubMed database was searched for literature describing thyroid cancer with facial skeleton metastasis using the key words "thyroid," "cancer," "carcinoma," "metastasis," and "malignancy" with "oral cavity," "maxilla," "mandible," "sinus," "paranasal," and "orbit." Reports that only involved the soft tissues were excluded. Systematic review revealed 59 cases of well-differentiated thyroid cancer with facial skeleton metastasis: 35 mandibular metastases (21 = FTC), 6 maxilla metastases (2 = FTC), 9 orbital metastases (4 = FTC), and 11 paranasal sinus metastases (7 = FTC). Treatment included surgery, RAI, external beam radiotherapy (XRT), or a combination of these modalities. The one, two, and five-year survival rates were 100%, 79%, and 16%, respectively. CONCLUSION: Facial skeleton metastasis of FTC is a rare clinical challenge. Optimal treatment appears to include total thyroidectomy and resection of involved structures with or without adjuvant treatment.

The Effect of Financial Conflicts of Interest in Plastic Surgery Literature.

Medical research has a long history of joint venture between commercial entities and nonindustry researchers. Significant concern exists among accrediting bodies for medical education and federal granting agencies that conflicts of interest (COIs) exist that affect the validity of the research. This study evaluates the legitimacy of this concern.All clinical breast and cosmetic articles in Plastic and Reconstructive Surgery and Annals of Plastic Surgery were reviewed for calendar year 2013. If a financial disclosure was present, the article was then reviewed to determine if the subject/findings were in favor of the commercial conflict and, if so, whether the study was valid. To assess plastic surgery versus other specialties, articles from Dermatology and Journal of Bone and Joint Surgery were similarly reviewed from January to April of 2013.Two hundred seventy-two clinical articles were reviewed. Only 15 (5.5%) had a true COI: the article's findings favored the commercial interest of at least 1 author: for each journal, Plastic and Reconstructive Surgery, 7.7%; Annals of Plastic Surgery, 3.3%; Dermatology, 2.2%; Journal of Bone and Joint Surgery, 7.5%. Conflicts of interest were not statistically significant between pooled articles of plastic surgery versus dermatology/orthopedics. However, COI was statistically greater (P = 0.05) in Plastic and Reconstructive Surgery compared with Annals and Dermatology.Despite public and regulatory concerns, this assessment demonstrates that the peer-review process of leading journals polices true COIs. Published articles provide sound research despite presumed COIs. As such, the integrity and validity of published research remain high.

Risk Factor Analysis for Mastectomy Skin Flap Necrosis: Implications for Intraoperative Vascular Analysis.

INTRODUCTION: Skin flap necrosis after mastectomy can be a devastating complication significantly affecting patient outcomes. Routine vascular analysis (fluorescein or laser angiography) of mastectomy skin flaps in all patients has been advocated but is of questionable cost-effectiveness. The purpose of this study was to identify the incidence and causative risk factors for mastectomy skin flap necrosis and thereby calculate the fiscal reality of intraoperative vascular screening. METHODS: This is an institutional review board-approved retrospective study of all patients from 2007 to 2013 who underwent mastectomy related to breast cancer. Skin flap necrosis was defined as major if it necessitated return to the operating room. Data analysis was done for determination of causative factors of necrosis, including age, body mass index, smoking, previous irradiation, coronary artery disease, chronic obstructive pulmonary disorder, hypertension, gastroesophageal reflux disease, hyperlipidemia, obstructive sleep apnea, asthma, diabetes, thyroid disease, history of lumpectomy, and breast reduction or augmentation. During this time, intraoperative vascular screening was not done. RESULTS: Five hundred eighty-one patients underwent 616 mastectomies with a total of 34 necrotic events (5.5%)-16 major and 18 minor. Analyses via Student t tests, univariate analyses, χ testing, and logistic regression showed that history of smoking was the only patient factor associated with postoperative necrosis (P = 0.008). More frequently represented in the necrosis group, but without statistical significance, are previous lumpectomy (P = 0.069) and immediate reconstruction (P = 0.078).For the entire study period, the actual cost to the hospital for major necrotic events was $7,123.10 or $445.19 for each of the 16 major necrotic events and $209.50 for all 34 necrotic events. Per-patient cost-effective screening would need to be less than $11.54 for all patients, $100.33 for highest risk patients (smokers), and $21.65 for highest risk patients (smokers, previous lumpectomy, and immediate reconstruction). CONCLUSIONS: Vascular screening other than clinical judgment of all patients is not cost effective. However, intraoperative vascular evaluation of high-risk patients is recommended before reconstruction and/or closure. These financial data that incorporate true costs and revenue can guide the use of newer, more expensive technology such as laser angiography and can be extrapolated to other institutions.

Substance use and mental illness among nurses: workplace warning signs and barriers to seeking assistance.

BACKGROUND: Although some studies have examined the prevalence of substance use among nurses, few have assessed substance use in the workplace or early cues for identifying these health conditions. Primary data collected as part of a larger program evaluation were examined with the purpose of better understanding (a) the context and perceived consequences of substance use and mental illness among nurses and (b) barriers and opportunities for earlier identification and treatment of these issues among nurses, their colleagues, and employers. METHODS: Anonymous surveys were mailed to 441 active and recent participants of a peer health assistance program in the summer of 2010. The survey examined drug-related behaviors in the workplace; behavioral cues that may permit earlier identification of substance use and mental illness; perceptions of barriers to seeking assistance; and strategies for preventing problems and overcoming barriers to seeking assistance. RESULTS: Responses were received from 302 nurses (69%). Nearly half (48%) reported drug or alcohol use at work, and two fifths (40%) felt that their competency level was affected by their use. More than two thirds of respondents thought their problem could have been recognized earlier. The most highly rated barriers to seeking assistance for substance use and mental illness included fear and embarrassment and concerns about losing one's nursing license. Respondents recommended greater attention be paid to early identification of risk factors during nurses' professional training as a prevention strategy. CONCLUSIONS: Findings from this study provide preliminary data that can be used by schools of nursing and health care employers to improve early identification of nurses' substance use and mental illness treatment needs. These data also suggest a need for more research to explore the prevention and early identification of co-occurring disorders in health care settings where nurses practice.

Screening, brief intervention, and referral to treatment (SBIRT) as an integral part of nursing practice.

ABSTRACT. Substance use screening, brief intervention, and referral to treatment (SBIRT) should be an integral part of the scope of nursing practice. This commentary is an appeal for nurses to advance their knowledge and competencies related to SBIRT. The question of how to move SBIRT into the mainstream of nursing practice was posed to several leaders of federal agencies, health care and nursing organizations, nurse educators, and nurse leaders. The authors provide recommendations for moving this set of clinical strategies (i.e., SBIRT) into day-to-day nursing practice.

Digitally-Enabled Peer Support and Social Health Platform for Vulnerable Adults with Symptomatic Mental Illness: Cohort Analysis.

UNSTRUCTURED: Loneliness, depression, and anxiety are highly prevalent among US adults, especially among socio-demographically vulnerable populations. Virtual peer support is a potentially cost-effective, scalable intervention. This study prospectively evaluated the effects of digitally-enabled peer support on mental health outcomes and estimated medical cost reductions among 243 vulnerable adults with symptomatic depression, anxiety, and significant loneliness. We found that participants from diverse race/ethnicities, genders and socio-economic groups engaged with peer support and experienced statistically and clinically significant improvements in their mental health and an estimated annual medical costs reduction of $1,025 per participant. We believe this work will inform ongoing discussions related to the use of digitally-enabled peer support to address the mental health crisis in the US.

Methodology for Robotic In Vitro Testing of the Knee.

The knee joint plays a pivotal role in mobility and stability during ambulatory and standing activities of daily living (ADL). Increased incidence of knee joint pathologies and resulting surgeries has led to a growing need to understand the kinematics and kinetics of the knee. In vivo, in silico, and in vitro testing domains provide researchers different avenues to explore the effects of surgical interactions on the knee. Recent hardware and software advancements have increased the flexibility of in vitro testing, opening further opportunities to answer clinical questions. This paper describes best practices for conducting in vitro knee biomechanical testing by providing guidelines for future research. Prior to beginning an in vitro knee study, the clinical question must be identified by the research and clinical teams to determine if in vitro testing is necessary to answer the question and serve as the gold standard for problem resolution. After determining the clinical question, a series of questions (What surgical or experimental conditions should be varied to answer the clinical question, what measurements are needed for each surgical or experimental condition, what loading conditions will generate the desired measurements, and do the loading conditions require muscle actuation?) must be discussed to help dictate the type of hardware and software necessary to adequately answer the clinical question. Hardware (type of robot, load cell, actuators, fixtures, motion capture, ancillary sensors) and software (type of coordinate systems used for kinematics and kinetics, type of control) can then be acquired to create a testing system tailored to the desired testing conditions. Study design and verification steps should be decided upon prior to testing to maintain the accuracy of the collected data. Collected data should be reported with any supplementary metrics (RMS error, dynamic statistics) that help illuminate the reported results. An example study comparing two different anterior cruciate ligament reconstruction techniques is provided to demonstrate the application of these guidelines. Adoption of these guidelines may allow for better interlaboratory result comparison to improve clinical outcomes.

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis.

Importance: Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. Objective: To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. Design, Setting, and Participants: This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Exposure: Continuation of antibiotics after appendectomy. Main Outcomes and Measures: Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. Results: A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Conclusions and Relevance: Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Antibiotic therapy and necrotizing enterocolitis.

Antibiotic therapy remains a cornerstone of treatment of both medical and surgical presentations of necrotizing enterocolitis (NEC). However, guidelines regarding the administration of antibiotics for the treatment of NEC are lacking and practices vary amongst clinicians. Although the pathogenesis of NEC is unknown, there is consensus that the infant gastrointestinal microbiome contributes to the disease. The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC. Yet others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC by inducing a state of dysbiosis. This narrative review summarizes what is known about antibiotics and their association with the infant microbiome and NEC, current antibiotic prescribing practices for infants with medical and surgical NEC, as well as potential strategies to further optimize the use of antibiotics in this population of infants.

Digitally Enabled Peer Support Intervention to Address Loneliness and Mental Health: Prospective Cohort Analysis.

BACKGROUND: Social isolation and loneliness affect 61% of US adults and are associated with significant increases in excessive mental and physical morbidity and mortality. Annual health care spending is US $1643 higher for socially isolated individuals than for those not socially isolated. OBJECTIVE: We prospectively evaluated the effects of participation with a digitally enabled peer support intervention on loneliness, depression, anxiety, and health-related quality of life among adults with loneliness. METHODS: Adults aged 18 years and older living in Colorado were recruited to participate in a peer support program via social media campaigns. The intervention included peer support, group coaching, the ability to become a peer helper, and referral to other behavioral health resources. Participants were asked to complete surveys at baseline, 30, 60, and 90 days, which included questions from the validated University of California, Los Angeles Loneliness Scale, Patient Health Questionnaire 2-Item Scale, General Anxiety Disorder 7-Item Scale, and a 2-item measure assessing unhealthy days due to physical condition and mental condition. A growth curve modeling procedure using multilevel regression analyses was conducted to test for linear changes in the outcome variables from baseline to the end of the intervention. RESULTS: In total, 815 ethnically and socially diverse participants completed registration (mean age 38, SD 12.7; range 18-70 years; female: n=310, 38%; White: n=438, 53.7%; Hispanic: n=133, 16.3%; Black: n=51, 6.3%; n=263, 56.1% had a high social vulnerability score). Participants most commonly joined the following peer communities: loneliness (n=220, 27%), building self-esteem (n=187, 23%), coping with depression (n=179, 22%), and anxiety (n=114, 14%). Program engagement was high, with 90% (n=733) engaged with the platform at 60 days and 86% (n=701) at 90 days. There was a statistically (P<.001 for all outcomes) and clinically significant improvement in all clinical outcomes of interest: a 14.6% (mean 6.47) decrease in loneliness at 90 days; a 50.1% (mean 1.89) decline in depression symptoms at 90 days; a 29% (mean 1.42) reduction in anxiety symptoms at 90 days; and a 13% (mean 21.35) improvement in health-related quality of life at 90 days. Based on changes in health-related quality of life, we estimated a reduction in annual medical costs of US $615 per participant. The program was successful in referring participants to behavioral health educational resources, with 27% (n=217) of participants accessing a resource about how to best support those experiencing psychological distress and 15% (n=45) of women accessing a program about the risks of excessive alcohol use. CONCLUSIONS: Our results suggest that a digitally enabled peer support program can be effective in addressing loneliness, depression, anxiety, and health-related quality of life among a diverse population of adults with loneliness. Moreover, it holds promise as a tool for identifying and referring members to relevant behavioral health resources.

Outcomes and Resource Utilization Associated with Use of Routine Pre-Discharge White Blood Cell Count for Clinical Decision-Making in Children with Complicated Appendicitis: A Multicenter Hospital-Level Analysis.

BACKGROUND: The objective was to explore the hospital-level relationship between routine pre-discharge WBC utilization (RPD-WBC) and outcomes in children with complicated appendicitis. METHODS: Multicenter analysis of NSQIP-Pediatric data from 14 consortium hospitals augmented with RPD-WBC data. WBC were considered routine if obtained within one day of discharge in children who did not develop an organ space infection (OSI) or fever during the index admission. Hospital-level observed-to-expected ratios (O/E) for 30-day outcomes (antibiotic days, imaging utilization, healthcare days, and OSI) were calculated after adjusting for appendicitis severity and patient characteristics. Spearman correlation was used to explore the relationship between hospital-level RPD-WBC utilization and O/E's for each outcome. RESULTS: 1528 children were included. Significant variation was found across hospitals in RPD-WBC use (range: 0.7-100%; p < 0.01) and all outcomes (mean antibiotic days: 9.9 [O/E range: 0.56-1.44, p < 0.01]; imaging: 21.9% [O/E range: 0.40-2.75, p < 0.01]; mean healthcare visit days: 5.7 [O/E 0.74-1.27, p < 0.01]); OSI: 14.1% [O/E range: 0.43-3.64, p < 0.01]). No correlation was found between RPD-WBC use and antibiotic days (r = +0.14, p = 0.64), imaging (r = -0.07, p = 0.82), healthcare days (r = +0.35, p = 0.23) or OSI (r = -0.13, p = 0.65). CONCLUSIONS: Increased RPD-WBC utilization in pediatric complicated appendicitis did not correlate with improved outcomes or resource utilization at the hospital level. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Clinical Research.

Infections in the NICU: Neonatal sepsis.

Neonatal infections remain an important cause of neonatal morbidity and mortality worldwide. Neonatal sepsis is a systemic infection that can be classified as early-onset or late-onset pending the timing of presentation. The pathophysiology and causative pathogens of neonatal sepsis vary, with early-onset sepsis being associated with a vertically transmitted infection from mother to neonate versus late onset sepsis being commonly associated with nosocomial infections. The signs and symptoms of neonatal sepsis mimic those associated with prematurity, making timely diagnosis difficult for treating clinicians. The management of neonatal sepsis is centered around obtaining adequate culture data and initiation of broad-spectrum parenteral antibiotics. Controversies surrounding the management of neonatal sepsis include the administration of empiric antibiotics, given recent clinical studies associating early antibiotic use with clinical sequelae such as late-onset sepsis, necrotizing enterocolitis, and death in the preterm, low-birthweight infant population.

The NICU Antibiotics and Outcomes (NANO) trial: a randomized multicenter clinical trial assessing empiric antibiotics and clinical outcomes in newborn preterm infants.

BACKGROUND: Early-onset sepsis is an important cause of neonatal morbidity and mortality in the preterm population. Infants perceived to be at increased risk for early-onset sepsis are often treated empirically with broad-spectrum antibiotics while awaiting confirmatory blood cultures, despite an overall incidence of early-onset sepsis of 2-3% among extremely-low-birthweight (ELBW) infants. Recent observational studies associate perinatal antibiotic use with an increased incidence of necrotizing enterocolitis, late-onset sepsis, and mortality among ELBW infants. Given currently available data and variability in clinical practice, we designed a prospective multi-institutional randomized controlled trial to determine the safety of early antibiotic use in ELBW infants. METHODS: The NICU Antibiotics and Outcomes (NANO) trial is a multicenter, double-blinded, randomized controlled trial. A sample of 802 ELBW preterm infants will undergo web-based stratified block randomization to receive empiric antibiotics (EA; ampicillin and gentamicin) or placebo during routine evaluation for early-onset sepsis. Participating sites will use preexisting institutional protocols for antibiotic dosage and duration. Infants born at participating sites with a gestational age of 29 weeks or less are eligible for enrollment. Exclusion criteria include maternal intrauterine infection, hemodynamic or respiratory instability, delivery by caesarean section for maternal indications without labor or prolonged rupture of membranes, and prior administration of antibiotics. The primary outcome is the composite incidence of necrotizing enterocolitis, late-onset sepsis, or death during participants' index hospitalization. Maternal and infant samples will be collected longitudinally and assessed for differences in microbiome composition and diversity. DISCUSSION: The NANO trial is designed to compare the rate of adverse outcomes of EA use at birth versus placebo in ELBW preterm infants. If EA at birth worsens clinical outcomes, then the results of the trial may help providers decrease antibiotic utilization in the NICU and subsequently decrease the incidence of complications associated with early antibiotic use in ELBW infants. If we instead find that EA improve outcomes, then the trial will validate a longstanding clinical practice that has not previously been supported by high-quality data. Future studies will assess long-term clinical and microbial outcomes in infants who received empiric antibiotics following delivery. TRIAL REGISTRATION: Trial registration data: June 25, 2019  NCT03997266 .

Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis.

Importance: The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis. Objective: To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization. Design, Setting, and Participants: This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020. Exposures: The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports. Main Outcomes and Measures: The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals. Results: Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001). Conclusions and Relevance: In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.

Long-Term Neurodevelopmental and Functional Outcomes of Normally Developing Children Requiring PICU Care for Bronchiolitis.

Bronchiolitis is a common pediatric intensive care unit (PICU) illness and often affects generally healthy children, making it a promising disease in which to study long-term neurodevelopmental outcomes. We previously found that approximately 15% of critical bronchiolitis patients have evidence of post-PICU morbidity using coarse definitions available in administrative data sets. In this study, we measured neurodevelopmental outcomes using four more precise tools. Children who had previously been admitted to our PICU with bronchiolitis were included; those with evidence of developmental delay at PICU admission were excluded. Approximately 1 to 2 years after PICU discharge, the parent of each subject completed two questionnaires (Ages and Stages Questionnaire and Pediatric Evaluation of Disability Inventory Computer Adaptive Test). Each subject also underwent two in-person assessments administered by a certified examiner (Bayley Scales of Infant and Toddler Development, 3rd edition, and the Amiel-Tison neurological assessment). For each domain of each test, a score of > 1 standard deviation below the norm for the subject's age defined "moderate" disability and a score ≥ 2 standard deviations below the norm defined "severe" disability. Eighteen subjects (median ages of 3.7 months at PICU admission and 2.3 years at testing) were enrolled, 17 of whom were supported by high-flow nasal cannula and/or mechanical ventilation. Fifteen children (83%) scored abnormally on ≥ 1test. Eight children (44%) had disabilities in ≥ 3 domains and/or ≥ 1 severe disability identified. Our findings that motor, language, and cognitive disabilities are commonly observed months to years after critical bronchiolitis require larger studies to confirm this finding, assess causality, and identify modifiable risk factors.