Kawasaki Disease and Clinical Outcome Disparities Among Black Children.

OBJECTIVE: To determine whether Black children with Kawasaki disease exhibit disparities in prevalence, sequelae, and response to intravenous gamma globulin (IVIG) treatment. STUDY DESIGN: International Classification of Diseases codes were used to identify children with Kawasaki disease admitted to a tertiary center in the southeastern US. Subjects diagnosed and treated according to American Heart Association criteria were included. Demographic, laboratory, clinical, and echocardiographic data from the electronic medical record (2000-2015) were compared between Blacks and Whites. RESULTS: Data from 369 subjects (52% Whites and 48% Blacks) were included in our analysis. No significant differences related to timely admission, IVIG treatment, or coronary artery (CA) abnormalities during hospitalization were observed. Blacks showed lower IVIG response rates than Whites for patients administered IVIG within 10 days of fever onset (86.6% vs 95.6%; P = .007). Blacks received more ancillary drugs (9.6% vs 2.6%; P = .003), and endured longer hospitalizations (mean, 5 ± 3.9 days vs 3.4 ± 2.2 days; P = .001). Blacks presented with higher C-reactive protein level and erythrocyte sedimentation rate and lower hemoglobin, albumin, and sodium levels. Blacks had a higher proportion of persistent CA abnormalities than Whites at second follow-up echocardiogram (14.5% vs 6.3%; P = .03), and at third follow-up echocardiogram (21.2% vs 6.9%; P = .01). CONCLUSIONS: Compared with White children, Black children with Kawasaki disease had higher IVIG refractory prevalence, more severe inflammation, more ancillary treatments, and longer hospitalizations. Despite no racial differences in time to diagnosis or initial treatment, there was greater CA abnormality persistence among Black children at follow-up.

Impact of induction strategy change on first-year rejection in pediatric heart transplantation at a single center-From postoperative basiliximab to either postoperative anti-thymocyte globulin or preoperative basiliximab.

BACKGROUND: Our pediatric heart transplant center transitioned from post-bypass basiliximab (BAS) induction to either anti-thymocyte globulin (ATG) or pre-bypass BAS. The purpose of this study was to compare first-year rejection rates before and after this change. METHODS: A single-center retrospective analysis was conducted of pediatric heart transplant recipients from 2010 to 2019. Primary outcome was first-year rejection. Bivariate analysis, Kaplan-Meier curves, and multivariable regression were performed across eras. RESULTS: Forty-three early era patients (55%) received post-bypass BAS, and 35 late era patients (45%) received pre-bypass BAS (n = 17) or ATG (n = 18). First-year rejection decreased in the late era (31% vs 53%, p = .05). This finding was more pronounced after excluding infants (38% vs 73%, p = .006). Late era was associated with a decreased likelihood of rejection (all cohort OR 0.19, 95% CI 0.05-0.66; infants excluded OR 0.17, 95% CI 0.04-0.61). No differences in post-transplant lymphoproliferative disease, donor-specific antibody, or infection were observed. CONCLUSIONS: Fewer late era patients receiving ATG or pre-bypass BAS induction had first-year rejection compared to the early era patients receiving standard post-bypass BAS induction. This programmatic shift in induction strategy was readily achievable and potentially effective in reducing first-year rejection.

Examining racial and socioeconomic disparity in the pediatric heart transplant evaluation.

Racial disparities have been reported among pediatric patients waitlisted for and undergoing heart transplantation but have not been studied further upstream in the transplant candidate evaluation process. We retrospectively studied our single-center experience in order to investigate any potential biases in the evaluation process. Results of the heart transplant evaluation in children ≤18 years old at our institution were analyzed. Primary outcome was final disposition to waitlist or not. Race was defined by family self-identification. Descriptive and comparative statistical analyses were performed. From 2013 to 2019, 133 unique patients were referred for listing consideration. While Black patients comprised 44% of the referral population and had more markers of socioeconomic disadvantage, they comprised 43% of the patients who were listed for transplantation with no significant difference between these proportions (p = .96). Black and White patients made up a similar proportion of patients deemed too well or too ill for listing. Black patients had lower annual household income estimates and rates of household marriage. Despite identifying significant social challenges in 27 patients (18 of them Black), only five patients (3 Black and 2 White) were turned down for listing due to social barriers. While limited by the small number of patients turned down for social barriers, our transplant evaluation process does not appear to result in racial disparities in access to listing. Further studies are needed using national cohorts to explore possible racial disparities upstream from waitlisting and transplantation, such as during the referral and evaluation.

Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Variants on Short- and Mid-term Cardiac Outcomes in Multisystem Inflammatory Syndrome in Children.

Cardiac outcomes of 131 children with multisystem inflammatory syndrome (MIS-C) were examined. The majority of the cohort was male (66.4%) and half were Black (49.6%). Cardiac involvement was evident in 25% of the cohort at diagnosis. Favorable short- and mid-term outcomes were documented on follow-up, irrespective of the severe acute respiratory syndrome coronavirus 2 variants causing the infection.

STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic medical centre.

SETTING: Massachusetts General Hospital embarked on a 4-year project to reduce readmissions in a high volume general medicine unit (November 2009 to September 2013). OBJECTIVE: To reduce 30-day readmissions to 10% through improved care coordination. DESIGN: As a before-after study, a total of 7586 patients admitted to the medicine unit during the intervention period included 2620 inpatients meeting high risk for readmission criteria. Of those, 2620 patients received nursing interventions and 539 patients received pharmacy interventions. INTERVENTION: The introduction of a Discharge Nurse (D/C RN) for patient/family coaching and a Transitional Care Pharmacist (TC PharmD) for predischarge medication reconciliation and postdischarge patient phone calls. Other interventions included modifications to multidisciplinary care rounds and electronic medication reconciliation. MAIN OUTCOME MEASURE: All-cause 30-day readmission rates. RESULTS: Readmission rates decreased by 30% (21% preintervention to 14.5% postintervention) (p<0.05). From July 2010 to December 2011, rates of readmission among high-risk patients who received the D/C RN intervention with or without the TC PharmD medication reconciliation/education intervention decreased to 15.9% (p=0.59). From January to June 2010, rates of readmission among high-risk patients who received the TC PharmD postdischarge calls decreased to 12.9% (p=0.55). From June 2010 to December 2011, readmission rates for patients on the medical unit that did not receive the designated D/C RN or TC PharmD interventions decreased to 15.8% (p=0.61) and 16.2% (0.31), respectively. CONCLUSIONS: A multidisciplinary approach to improving care coordination reduced avoidable readmissions both among those who received interventions and those who did not. This further demonstrated the importance of multidisciplinary collaboration.

Ethnicity and diagnosis in patients with affective disorders.

BACKGROUND: Clinically, African American psychiatric patients are disproportionately diagnosed with schizophrenia compared with white patients. Why this occurs is unknown. Extending prior work, the authors hypothesized that first-rank symptoms distract clinicians so that they fail to identify affective disorders in African Americans. METHOD: 195 African American and white patients with at least 1 psychotic symptom (delusions, hallucinations, or prominent thought disorder) at admission were recruited from January 1, 1998, through May 31, 2001. Each patient received 3 independent DSM-IV diagnoses: a clinical diagnosis, a structured-interview diagnosis, and an expert-consensus diagnosis. The expert-consensus diagnoses were derived from the structured interviews, which were audiotaped and transcribed, and medical records. After reviewing edited transcripts and medical records from which ethnic cues had been eliminated, 2 psychiatrists assigned expert-consensus diagnoses and first-rank symptom ratings. For the 79 patients who received an expert-consensus diagnosis of an affective disorder, clinical variables, diagnoses, and first-rank symptoms were compared between African American (N = 39) and white (N = 40) patients. RESULTS: Seventy-nine (41%) of 195 patients were diagnosed with an affective disorder by expert consensus. African American men with an expert-consensus affective disorder were significantly (p <.03) more likely than other patients to be diagnosed with a schizophrenia spectrum disorder by clinical assessment and structured interview. Although first-rank symptoms were more commonly identified in African American men, this finding did not explain the difference in diagnoses. Post hoc analyses suggested that African American men diagnosed with a schizophrenia spectrum disorder were more likely than other patients to have been identified during structured interview as having psychotic symptoms in the absence of affective symptoms. CONCLUSION: The apparent misdiagnosis of schizophrenia in African-Americans with mood disorders cannot be ascribed to differences in first-rank symptoms. However, it may be due to a perception that psychotic symptoms are more chronic or persistent than affective symptoms in these patients.

Ethnicity and first-rank symptoms in patients with psychosis.

Previous studies suggested that African-American patients with psychotic disorders present more commonly with first-rank symptoms. However, it was unclear whether these results reflected true differences among African- and Euro-Americans in symptom presentation or instead resulted from raters being more likely to assign first-rank symptoms to African-American patients. In this study, a total of 195 African- and Euro-American patients presenting for hospitalization with psychosis were evaluated using structured diagnostic and symptom rating instruments; this evaluation was audiotaped. The tapes were transcribed and all cues indicating the patient's ethnicity were edited from the transcript and from medical records. Two board-certified psychiatrists then evaluated the transcripts and medical records in order to make consensus expert diagnosis and rate first-rank symptoms. Ratings of first-rank symptoms in African- and Euro-American patients were compared between ethnicity-blinded expert consensus assessments and the unblinded structured interview. African-American men received higher first-rank symptom ratings than the remaining patient groups by both ethnicity-blinded expert consensus and unblinded structured interview. African-American men also had significantly more total psychotic symptoms than Euro-American men. However, the ethnically blinded expert consensus did not find an increased rate of schizophrenia in the African-American men. These findings indicate that psychotic symptom presentation should be evaluated in the context of other symptoms (e.g., affective symptoms) in diagnostic assessments in order to prevent misdiagnoses of schizophrenia.

Outcomes of a clinical nurse specialist-initiated wound care education program: using the promoting action on research implementation in health services framework.

Consistent with the sphere of clinical nurse specialist (CNS) practice related to advancing nursing practice and patient outcomes, a CNS task force of 20 of the 60 CNSs in our large teaching hospital was convened to plan, implement and evaluate a comprehensive wound care education program. The purpose of the program was to ensure the 24-7 hospital-wide availability of nurses with evidenced-based wound care knowledge and skills. The facilitative environment, in which the program was developed and operates, is analyzed using the Promoting Action on Research Implementation in Health Services framework. Outcomes of the CNS task force include (1) designation of unit-based CNS as the first line resources for wound care at the unit level, (2) education of almost 10% of the 3,800 nurses at Massachusetts General Hospital as staff nurse resources, and (3) a shift in the nature of CNS wound care consultations from prescription to validation of the staff nurse-initiated wound care plan.