RESUMO
INTRODUCTION: Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. METHODS: Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children's hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. RESULTS: After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. CONCLUSION: Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.
RESUMO
Both genetic and environmental factors are known to influence the structure of bone, contributing to its mechanical behavior during, and adaptive response to, loading. We introduce a novel approach to simultaneously address the genetically mediated, exercise-related effects on bone morphometrics and strength, using mice that had been selectively bred for high levels of voluntary wheel running (16 generations). Female mice from high running and control lines were either allowed (n=12, 12, respectively) or denied (n=11, 12, respectively) access to wheels for 20 months. Femoral shaft, neck, and head were measured with calipers and via micro-computed tomography. Fracture characteristics of the femoral head were assessed in cantilever bending. After adjusting for variation in body mass by two-way analysis of covariance, distal width of the femur increased as a result of selective breeding, and mediolateral femoral diameter was reduced by wheel access. Cross-sectional area of the femoral mid-shaft showed a significant linetype x activity effect, increasing with wheel access in high-running lines but decreasing in control lines. Body mass was significantly positively correlated with many of the morphometric traits studied. Fracture load of the femoral neck was strongly positively predicted by morphometric traits of the femoral neck (r2>0.30), but no significant effects of selective breeding or wheel access were found. The significant correlations of body mass with femoral morphometric traits underscore the importance of controlling for body size when analyzing the response of bone size and shape to experimental treatments. After controlling for body mass, measures of the femoral neck remain significant predictors of femoral neck strength.