CXCR4/IgG-expressing plasma cells are associated with human gastrointestinal tissue inflammation.

BACKGROUND: We previously reported abnormalities in circulating B cells in patients with chronic granulomatous disease (CGD) and those with HIV infection. Gastrointestinal complications are common to both diseases and likely involve perturbation of immune cells, including plasma cells (PCs). IgA is the most abundant immunoglobulin in the human body, with roles in protection and maintenance of intestinal homeostasis. IgA is produced primarily by PCs residing in mucosal tissues that are also thought to circulate in the blood. OBJECTIVE: We sought to characterize and compare PCs in patients with infectious (HIV) and noninfectious (CGD and Crohn disease) diseases that have been associated with intestinal inflammation. METHODS: Phenotypic and transcriptional analyses were performed on cells isolated from the blood and colon. RESULTS: IgA-secreting CCR10-expressing PCs predominated in the guts of healthy subjects, whereas in patients with HIV, CGD, and Crohn disease, there was a significant increase in the proportion of IgG-secreting PCs. Where intestinal inflammation was present, IgG-secreting PCs expressed reduced levels of CCR10 and increased levels of CXCR4. The intensity of CXCR4 expression correlated with the frequency of IgG-expressing PCs and the frequency of CXCR4(+)/IgG(+) PCs was associated with the severity of intestinal inflammatory disease yet distinct from PCs and plasmablasts circulating in the blood. CONCLUSIONS: These findings suggest that regardless of the underlying disease, the presence of CXCR4(+)/IgG(+) PCs in the gut is a strong yet localized indicator of intestinal inflammation. Furthermore, our findings suggest that CXCR4(+)/IgG(+) PCs might play a role in immune cell homeostasis during inflammatory processes of the gut.

A Practical Guide to QI Data Analysis: Run and Statistical Process Control Charts.

Data analysis utilizing run charts and statistical process control (SPC) charts is a mainstay of quality improvement (QI) work. These types of time series analyses allow QI teams to evaluate patterns in data that may not be apparent with pre- and postintervention analysis. A run chart is most useful at the onset of a project when data points may be limited; points can be added prospectively to monitor for changes. An SPC chart is needed to determine if the system is "out of control," indicating an instance of special cause variation, and is recommended for more robust data analysis. These charts are valuable tools in identifying patterns of change, but cannot indicate what caused the change. QI teams can further investigate significant patterns to identify the impact of interventions and promote continued change or sustainability. In this article, we will provide a practical guide to the basics of run and SPC charts, including how to create and interpret them. The reader can use the supplemental data tables to gain the skills needed to build their own charts with readily available software. Finally, we will review more specialized software options that can assist in creation of run and SPC charts.

Parental Factors Affecting Pediatric Medication Management in Underserved Communities.

BACKGROUND: Medication errors and adverse drug events are common in the pediatric population. Limited English proficiency and low health literacy have been associated with decreased medication adherence, increased medication errors, and worse health outcomes. This study explores parental factors affecting medication management in underserved communities. METHODS: Using qualitative methods, we identified factors believed to affect medication management among parents. We conducted focus group discussions between December 2019 and September 2020. We recruited parents and health care professionals from local community partners and a tertiary care children's hospital. Sessions were recorded and transcribed. Three investigators created the coding scheme. Two investigators independently coded each focus group and organized results into themes using thematic analysis. RESULTS: Eleven focus groups were held (n = 45): 4 English-speaking parent groups (n = 18), 3 Spanish-speaking parent groups (n = 11), and 4 health care professional groups (n = 16). We identified 4 main factors that could impact medication delivery: 1) limited health literacy among parents and feeling inadequate at medication administration (knowledge/skill gap), 2) poor communication between caregivers (regarding medication delivery, dosage, frequency, and purpose) and between providers (regarding what has been prescribed), 3) lack of pediatric medication education resources, and 4) personal attitudes and beliefs that influence one's medication-related decisions. CONCLUSIONS: The compounding effect of these factors - knowledge, communication, resource, and personal belief - may put families living in underserved communities at greater risk for medication errors and suboptimal health outcomes. These findings can be used to guide future interventions and may help optimize medication delivery for pediatric patients.

Geographic Variation in Acute Pediatric Mental Health Utilization.

OBJECTIVE: To identify locations with higher need for acute pediatric mental health (MH) interventions or services and describe these communities' socio-demographic characteristics. METHODS: This single-center retrospective study included patients 5 to 18 years old with an emergency department (ED) or hospital admission between 2017 and 2019 for a primary known MH diagnosis or symptoms. We extracted visit data from the electronic medical record, mapped patients to their home census tract, calculated normalized visit rates by census tract, and performed spatial analysis to identify nonrandom geographic clusters and outliers of high utilization. Census tract utilization rates were stratified into quartiles, and socioeconomic and demographic characteristics obtained from the US Census Bureau were compared using analysis of variance, chi-square tests, and multivariable analysis. RESULTS: There were 10,866 qualifying visits across 617 census tracts. ED and hospital admission rates ranged from 2.7 to 428.6 per 1000 children. High utilization clusters localized to neighborhoods with lower socioeconomic status (p < .05). Southern regions with high utilizers were more likely to have fewer children per neighborhood, higher rates of teen births, and lower socioeconomic status. Multivariate analysis showed regions with high utilizers had fewer children per neighborhood, lower median household income, and more families that lacked computer access. CONCLUSION: ED and hospital utilization for pediatric MH concerns varied significantly by neighborhood and demographics. Divergent social factors map onto these locations and are related to MH utilization. Leveraging geography can be a powerful tool in the development of targeted, culturally tailored interventions to decrease acute pediatric MH utilization and advance child MH equity.

Using emotion to guide decisions: the accuracy and perceived value of emotional intensity forecasts.

Forecasts about future emotion are often inaccurate, so why do people rely on them to make decisions? People may forecast some features of their emotional experience better than others, and they may report relying on forecasts that are more accurate to make decisions. To test this, four studies assessed the features of emotion people reported forecasting to make decisions about their careers, education, politics, and health. In Study 1, graduating medical students reported relying more on forecast emotional intensity than frequency or duration to decide how to rank residency programs as part of the process of being matched with a program. Similarly, participants reported relying more on forecast emotional intensity than frequency or duration to decide which universities to apply to (Study 2), which presidential candidate to vote for (Study 3), and whether to travel as Covid-19 rates declined (Study 4). Studies 1 and 3 also assessed forecasting accuracy. Participants forecast emotional intensity more accurately than frequency or duration. People make better decisions when they can anticipate the future. Thus, people's reports of relying on forecast emotional intensity to guide life-changing decisions, and the greater accuracy of these forecasts, provide important new evidence of the adaptive value of affective forecasts.

Detection of Neisseria gonorrhoeae from Joint Aspirate by Metagenomic Sequencing in Disseminated Gonococcal Infection.

Disseminated gonococcal infection (DGI) often manifests as gonococcal arthritis and may carry significant morbidity. However, diagnosis remains elusive due to limited sensitivity of available diagnostic tests. We used metagenomic next-generation sequencing to detect Neisseria gonorrhoeae from culture-negative joint aspirates of 2 patients with clinically diagnosed DGI.

A Quality Improvement Initiative To Improve Postdischarge Antimicrobial Adherence.

OBJECTIVES: Bedside delivery of discharge medications improves caregiver understanding and experience. Less is known about its impact on medication adherence. We aimed to improve antimicrobial adherence by increasing on-time first home doses for patients discharged from the pediatric hospital medicine service from 33% to 80% over 1 year via creation of a discharge medication delivery and counseling "Meds to Beds" (M2B) program. METHODS: Using sequential plan-do-study-act cycles, an interprofessional workgroup implemented M2B on select pediatric hospital medicine units at our quaternary children's hospital from October 2017 through December 2018. Scripted telephone surveys were conducted with caregivers of patients prescribed antimicrobial agents at discharge. The primary outcome measure was on-time administration of the first home antimicrobial dose, defined as a dose given within the time of the inpatient dose equivalent plus 25%. Process measures primarily assessed caregiver report of barriers to adherence. Run charts, statistical process control charts, and inferential statistics were used for data analysis. RESULTS: Caregiver survey response rate was 35% (207 of 585). Median on-time first home antimicrobial doses increased from 33% to 67% (P < .001). Forty percent of M2B prescriptions were adjusted before discharge because of financial or insurance barriers. M2B participants reported significantly less difficulty in obtaining medications compared with nonparticipants (1% vs 17%, P < .001). CONCLUSIONS: The M2B program successfully increased parental report of timely administration of first home antimicrobial doses, a component of overall adherence. The program enabled providers to identify and resolve prescription problems before discharge. Importantly, caregivers reported reduced barriers to medication adherence.

Optimistic expectations have benefits for effort and emotion with little cost.

The present investigation examined the potential benefits and costs of optimistic expectations about future events through the lens of error management theory (EMT). Decades of evidence have shown that optimism about the likelihood of future events is pervasive and difficult to correct. From an EMT perspective, this perpetuation of inaccurate beliefs is possible because optimism offers benefits greater than the costs. The present investigation examined this possibility for controllable important life events with a known time at which they would occur. College students taking their first exam (n = 1,061) and medical students being matched with residency placements (n = 182) reported their expectations and emotions weeks before the event and their responses after they knew the outcome of the event. Optimistic expectations predicted the quality of effort investment before an event occurred-students were more satisfied with their studying, medical students were more satisfied with their decision making, and optimism predicted better performance. Optimistic expectations also predicted less emotional distress before the event. There was no evidence that optimistic expectations related to longer-term greater distress when participants experienced an unexpected negative outcome; the valence of the outcome itself predicted distress. These results are consistent with the EMT-derived hypothesis that optimistic expectations have benefits for effort and emotion before an event occurs, with little cost after the outcome occurs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Integrating Undergraduate Patient Partners into Diabetes self-management education: Evaluating a free clinic pilot program for the Underserved.

BACKGROUND: Diabetes self-management education (DSME) improves glycemic control and health outcomes in patients with diabetes. OBJECTIVE: A process evaluation of a two-year pilot intervention examined the feasibility and acceptability of undergraduate volunteers as Patient Partners to foster DSME participation among the underserved.Design setting, and participants. In the setting of a student-run free clinic, 22 patients enrolled in DSME were paired with 16 undergraduate volunteers. During the DSME courses, Patient Partners assisted patients during classes, called patients weekly, and accompanied patients to clinic appointments.Key process evaluation results. Average attendance at DSME classes was 79.4% and 94.7% for patients and Patient Partners, respectively. Sixty-three percent of phone calls were successful and Patient Partners attended 50% of appointments with their patients. Focus groups demonstrated resounding acceptability of the Patient Partner role. CONCLUSIONS: Volunteer undergraduate Patient Partners are a beneficial adjunct to DSME delivery in the resource-constrained environment of a student-run free clinic.

An examination of child temperament as a predictor of parental post-operative analgesic administration.

BACKGROUND/PURPOSE: The purpose of this study was to examine children's temperament as a predictor of post-operative analgesics administered by parents after controlling for post-operative pain severity, surgery severity, and parental misconceptions regarding pain medication for children. METHODS: Participants included 286 Spanish- and English-speaking parents of children ages 1-18 (IQR: 3-8) undergoing outpatient elective surgery. Parents completed measures of baseline temperament, parental medication attitudes, and demographics preceding their child's surgery and recorded pain intensity and doses of analgesics administered (nonopioid and opioid) on postoperative days 1, 3, and 7. RESULTS: Pearson product-moment correlations revealed that emotionality was significantly associated with acetaminophen, ibuprofen and hydrocodone and shyness was significantly associated with acetaminophen and hydrocodone. Hierarchical linear regression analysis revealed emotionality as a significant independent predictor of acetaminophen, ibuprofen and hydrocodone administered (F(4, 72)=2.82, F(4, 73)=1.53, F(4, 58)=8.75, respectively). CONCLUSION: Dimensions of children's temperament, specifically emotionality, predict analgesic administration by parents following surgery even after controlling for confounding variables. These findings highlight the need for tailored interventions targeting management of children's pain in the home setting and suggest that both proximal (e.g., pain severity) and distal (e.g., child temperament) factors may be necessary intervention components.