What the COVID-19 Pandemic Teaches Us About Pediatric Iatrogenic Risk.

Iatrogenic morbidity and mortality are pediatric public health risks. This article considers how the COVID-19 pandemic illuminates these risks, as clinicians have been forced to navigate increased diagnostic uncertainty and changes to pediatric health care systems, including closures, limited staffing, and new infection control guidelines.

A Trainee-Led Quality Improvement Project Using Change Management Theory to Improve Bedside Rounding.

OBJECTIVE: The coronavirus disease 2019 pandemic disrupted the practice of family-centered rounds. After the height of the pandemic, a trainee-led team identified a low percentage of bedside rounds on general pediatrics resident teams and combined a quality improvement framework and change management theory to increase bedside rounds. Initial efforts focused on a single general pediatrics team with the aim to increase bedside rounds from 18% to 50% within 6 months and sustain improvement for 12 months. A second aim was to increase bedside rounds from 7% to 50% for all general pediatrics resident teams within 6 months of spread. METHODS: The Model for Improvement informed the identification of 3 primary drivers of bedside rounds: knowledge, culture, and logistics. Twelve plan-do-study-act (PDSA) cycles were implemented. Measures included the percentage of bedside rounds (primary outcome), caregiver attendance (secondary outcome), and nurse attendance and rounding time (balancing measures). RESULTS: For the initial team, 13 522 patient days were analyzed for the primary outcome with the average percentage of weekly bedside rounds increasing from 18% to 89% with 12 months of sustained improvement. The spread of the intervention to all teams revealed an increase in bedside rounding from 7% to 54%. The most significant improvements occurred after PDSA cycle 2, a communication bundle, and PDSA cycle 5, when the project was spread to all teams. CONCLUSIONS: This trainee-led initiative reveals the strength of the incorporation of change management theory within a quality improvement framework, resulting in rapid and sustainable increase in bedside rounds.

Sedation Practices in the PICU: An Unexpected Casualty of COVID-19.

Pediatric intensivists often use an "analgosedation" approach in mechanically ventilated children. By prioritizing analgesia and minimizing sedation, patients experience less delirium. However, when COVID-19 surged, our pediatric intensive care unit providers were tasked with caring for adults with severe acute hypoxemic respiratory failure (AHRF). As documented in the literature, adults with COVID-19-AHRF received significantly higher doses of sedatives than matched cohorts with non-COVID-19 AHRF. Surprisingly, when the pediatric intensive care unit returned to caring for children, a quality review showed that we were unintentionally using far more sedatives than that prior to COVID-19. This experience is not unique to our institution, or to COVID-19. Lingering effects of crisis care can persist beyond the event itself. We seek to share our experience in order to extend the conversation regarding the unexpected effects of crises on best practices and to stress the need for high-quality research on interventions to support mental health and resilience in frontline healthcare providers.

Characterization of monoclonal antibodies specific for the Merkel cell polyomavirus capsid.

Merkel cell polyomavirus (MCV) has been implicated as a causative agent in Merkel cell carcinoma. Robust polyclonal antibody responses against MCV have been documented in human subjects, but monoclonal antibodies (mAbs) specific for the VP1 capsid protein have not yet been characterized. We generated 12 mAbs capable of binding recombinant MCV virus-like particles. The use of a short immunogenic priming schedule was important for production of the mAbs. Ten of the 12 mAbs were highly effective for immunofluorescent staining of cells expressing capsid proteins. An overlapping set of 10 mAbs were able to neutralize the infectivity of MCV-based reporter vectors, with 50% effective doses in the low picomolar range. Three mAbs interfered with the binding of MCV virus-like particles to cells. This panel of anti-capsid antibodies should provide a useful set of tools for the study of MCV.

Merkel cell polyomavirus and two previously unknown polyomaviruses are chronically shed from human skin.

Mounting evidence indicates that Merkel cell polyomavirus (MCV), a circular double-stranded DNA virus, is a causal factor underlying a highly lethal form of skin cancer known as Merkel cell carcinoma. To explore the possibility that MCV and other polyomaviruses commonly inhabit healthy human skin, we developed an improved rolling circle amplification (RCA) technique to isolate circular DNA viral genomes from human skin swabs. Complete MCV genomes were recovered from 40% of healthy adult volunteers tested, providing full-length, apparently wild-type cloned MCV genomes. RCA analysis also identified two previously unknown polyomavirus species that we name human polyomavirus-6 (HPyV6) and HPyV7. Biochemical experiments show that polyomavirus DNA is shed from the skin in the form of assembled virions. A pilot serological study indicates that infection or coinfection with these three skin-tropic polyomaviruses is very common. Thus, at least three polyomavirus species are constituents of the human skin microbiome.