Adaptation to HLA-associated immune pressure over the course of HIV infection and in circulating HIV-1 strains.

Adaptation to human leukocyte antigen (HLA)-associated immune pressure represents a major driver of human immunodeficiency virus (HIV) evolution at both the individual and population level. To date, there has been limited exploration of the impact of the initial cellular immune response in driving viral adaptation, the dynamics of these changes during infection and their effect on circulating transmitting viruses at the population level. Capturing detailed virological and immunological data from acute and early HIV infection is challenging as this commonly precedes the diagnosis of HIV infection, potentially by many years. In addition, rapid initiation of antiretroviral treatment following a diagnosis is the standard of care, and central to global efforts towards HIV elimination. Yet, acute untreated infection is the critical period in which the diversity of proviral reservoirs is first established within individuals, and associated with greater risk of onward transmissions in a population. Characterizing the viral adaptations evident in the earliest phases of infection, coinciding with the initial cellular immune responses is therefore relevant to understanding which changes are of greatest impact to HIV evolution at the population level. In this study, we utilized three separate cohorts to examine the initial CD8+ T cell immune response to HIV (cross-sectional acute infection cohort), track HIV evolution in response to CD8+ T cell-mediated immunity over time (longitudinal chronic infection cohort) and translate the impact of HLA-driven HIV evolution to the population level (cross-sectional HIV sequence data spanning 30 years). Using next generation viral sequencing and enzyme-linked immunospot interferon-gamma recall responses to peptides representing HLA class I-specific HIV T cell targets, we observed that CD8+ T cell responses can select viral adaptations prior to full antibody seroconversion. Using the longitudinal cohort, we uncover that viral adaptations have the propensity to be retained over time in a non-selective immune environment, which reflects the increasing proportion of pre-adapted HIV strains within the Western Australian population over an approximate 30-year period.

The lived experience of patients with breast cancer on adjuvant endocrine therapy: side effects and coping strategies during the first year of medication initiation.

PURPOSE: Adjuvant endocrine therapy (AET) is pivotal for hormone receptor-positive breast cancer patients, significantly enhancing survival rates. Yet, adherence to AET remains challenging due to side effects. This study delves into the lived experience of breast cancer survivors concerning AET-induced side effects and examines differences in symptom profiles between Tamoxifen and aromatase inhibitors (AIs). METHODS: We interviewed 35 breast cancer survivors on AET, conducting qualitative iterative analysis using grounded theory. A codebook was developed to aid data coding and interpretation. NVIVO software facilitated comprehensive transcript analysis. RESULTS: Survivors reported a spectrum of side effects like hot flashes, sexual issues, joint pain, stiffness, mood swings, and fertility concerns. Symptom profiles differed based on AET type. Tamoxifen users experienced more frequent sexual side effects and mood swings, while AIs were linked to joint pain, stiffness, and bone health worries. Those on AET for over 6 months expressed heightened concerns about side effects. CONCLUSION: Tailored patient education, aligned with AET type, empowers survivors to manage side effects using self-regulatory strategies. Acknowledging distinct symptom profiles enables informed decisions, improving adherence and quality of life. IMPLICATIONS: This study underscores tailored survivorship support, equipping patients with tools to manage side effects, enhancing adherence, and long-term outcomes. The findings inform the integration of comprehensive survivorship programs, emphasizing individualized strategies for managing side effects and promoting better adherence and improved quality of life.

Evaluation of a nurse practitioner clinical practicum module using a capability education framework: A case study design.

AIMS AND OBJECTIVES: The aim of this research was to evaluate a nurse practitioner's clinical practicum module designed with a capability education framework. The objectives were to determine if the module prepared students adequately for their role and to determine if the Mini-CEX assessment tool was suitable for use with nurse practitioners. BACKGROUND: Capability is a necessary part of expertise, where a capable person takes responsibility to develop their own education, knowledge and skills. The capability learning framework offers nurse practitioners flexible learning pathways between the student, the university and clinical practice. This capability learning framework focuses on the wider complexities of nurse practitioner practice as opposed to a point-in-time assessment. DESIGN: A case study design was used. METHODS: Mixed methods including, document review, focus group and field notes were used in the case study evaluation adhering to the standards for the reporting of organisational case studies. RESULTS: A layered incremental approach to learning and assessments were applied. Students and assessors were satisfied with using the Mini-CEX assessment tool in the module. The Mini-CEX tool was familiar to clinical mentors, who compared students demonstrating competency in a similar manner to medicine. The feedback component of the tool provided deep and meaningful engagement for students. The module provided mentors with insight and understanding of the nurse practitioner role. Students identified the transitioning process from competent to capable practitioners. The module learning and assessments were mapped to regulatory nurse practitioner standards and requirements. CONCLUSIONS: The module provided comprehensive preparation for students to develop their nurse practitioner role. The Mini-CEX assessment tool is a fitting assessment for nurse practitioner students, particularly when supplemented with a corresponding reflective exercise. The assessments and feedback provided the students with opportunities to focus on agreed learning outcomes in their specialist area of practice. RELEVANCE TO CLINICAL PRACTICE: Nurse practitioners are required to practice autonomously and independently at a level of capability in clinical practice. The education preparation of nurse practitioner students must be directed appropriately.

Anticytomegalovirus CD4+ T Cells Are Associated With Subclinical Atherosclerosis in Persons With HIV.

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The management of delirium in the older adult in advanced nursing practice.

Delirium is a term used to describe an array of symptoms that indicate a disruption in cerebral metabolism, a condition that is often under-recognised, leading to delayed interventions. The condition is a common cause of older adults presenting in hospital, with significant morbidity and mortality associated with increased length of stay. A case study is used to illustrate the use of a diagnostic algorithm for older adults presenting with delirium to an advanced nurse practitioner (ANP)-led service. The clinical decision pathway provides four differential diagnoses, using the case study to put the decision-making process in context. The article demonstrates the ability of the ANP to practise at a high level of expertise as an autonomous practitioner and shows how the pathway supports the nurse to reach an accurate diagnosis. It shows that prompt and accurate diagnosis of delirium in older adults is crucial to avoiding the complications and cognitive decline associated with the condition.

Deep sequence analysis of HIV adaptation following vertical transmission reveals the impact of immune pressure on the evolution of HIV.

Human immunodeficiency virus (HIV) can adapt to an individual's T cell immune response via genomic mutations that affect antigen recognition and impact disease outcome. These viral adaptations are specific to the host's human leucocyte antigen (HLA) alleles, as these molecules determine which peptides are presented to T cells. As HLA molecules are highly polymorphic at the population level, horizontal transmission events are most commonly between HLA-mismatched donor/recipient pairs, representing new immune selection environments for the transmitted virus. In this study, we utilised a deep sequencing approach to determine the HIV quasispecies in 26 mother-to-child transmission pairs where the potential for founder viruses to be pre-adapted is high due to the pairs being haplo-identical at HLA loci. This scenario allowed the assessment of specific HIV adaptations following transmission in either a non-selective immune environment, due to recipient HLA mismatched to original selecting HLA, or a selective immune environment, mediated by matched donor/recipient HLA. We show that the pattern of reversion or fixation of HIV adaptations following transmission provides insight into the replicative cost, and likely compensatory networks, associated with specific adaptations in vivo. Furthermore, although transmitted viruses were commonly heavily pre-adapted to the child's HLA genotype, we found evidence of de novo post-transmission adaptation, representing new epitopes targeted by the child's T cell response. High-resolution analysis of HIV adaptation is relevant when considering vaccine and cure strategies for individuals exposed to adapted viruses via transmission or reactivated from reservoirs.

Enablers and challenges to advanced nursing and midwifery practice roles.

AIM: To describe the enablers and challenges to the development and implementation of advanced nursing and midwifery practice roles in Ireland. BACKGROUND: Leadership strategies need to be put in place to enhance the development and implementation of advanced nursing and midwifery practice roles. METHOD: A descriptive qualitative approach using semi-structured interviews with key stakeholders (n = 15) was undertaken with nurses and midwives working in specialist and advanced practice roles and participants from other areas such as legislative, regulatory, policy, pharmacy, medicine and education. RESULTS: Participant's perspectives on the enablers and challenges to enacting specialist and advanced practice roles resulted in the generation of three themes: organisational factors; collegial, interprofessional and interpersonal support; and role clarity, economic and regulatory contexts. CONCLUSION: Addressing organisational factors, encouraging collegial and interprofessional support and establishing role clarity contribute to the effective development and implementation of the role of advanced practitioners. IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT: Managers of nursing services need to provide leadership in developing strategies to enhance the enablers and overcome the challenges to advanced practice role development in their own organisation.

Kawasaki Disease Substantially Impacts Health-Related Quality of Life.

OBJECTIVE: To prospectively evaluate the acute impact of Kawasaki disease (KD) on health-related quality of life (HRQoL) and to assess deterioration in the HRQoL experienced by children with KD compared with other childhood diseases. STUDY DESIGN: We merged the Outcomes Assessment Program database obtained prospectively with the existing KD database and queried for KD admissions between 1 month and 13 years of age. HRQoL was evaluated with the parent-proxy Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core and Infant Scales. We compared the KD HRQoL results with those obtained from newly diagnosed patients with cancer and pneumonia, matched for age, sex and race. PedsQL total scores over time were assessed with ANCOVA models, adjusted for matching variables and PedsQL score prior to admission. RESULTS: We identified 89 patients with KD and compared 65 subjects with an equal number with pneumonia and with 67 subjects with newly diagnosed cancer. Patients with demonstrated lower PedsQL total score on admission and suffered a significantly greater HRQoL decline from baseline to admission than the other groups. KD diagnostic subtype (complete or incomplete) and coronary artery dilatation were not associated with HRQoL outcomes. However, non-intravenous immunoglobulin responders showed greater HRQoL decline than responders (P = .03). CONCLUSIONS: Children with KD suffer acute and significant HRQoL impairment exceeding that of children newly diagnosed with cancer. Lack of immediate treatment response may exert an additional HRQoL burden, whereas KD subtype and coronary artery dilatation do not.

Using State Administrative Data to Identify Social Complexity Risk Factors for Children.

PURPOSE: Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use. METHODS: We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use. RESULTS: Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14). CONCLUSIONS: State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

"Heart disease never entered my head": Women's understanding of coronary heart disease risk factors.

AIMS AND OBJECTIVES: This study investigated experiences of women with a primary diagnosis of ACS (NSTEMI & Unstable Angina). The study explored how women interpreted their risk for coronary heart disease (CHD) and how this influenced their treatment-seeking decisions. BACKGROUND: Efforts to reduce the incidence of cardiovascular disease, the number one killer of women, require aggressive risk factor modification, risk assessment and evidence-based treatments. CHD is largely preventable; however, despite the availability of evidence on prevention and risk factor reduction, it appears that misunderstandings persist. DESIGN: A naturalistic case study design guided this study. METHODS: Thirty women participated (n = 30); a within-case analysis was followed by a cross-case analysis. Data collection included participant diaries and face-to-face interviews. Data were analysed using modified analytic induction which allowed the emergence of theoretical insights. RESULTS: This article provides insight into women's perception of risk for CHD, particularly in relation to smoking. The findings provide a platform for a wider discourse on women's interpretation of their risk for CHD and their treatment-seeking decisions. The data reflect the ongoing misunderstanding that CHD affects men more than women. CONCLUSIONS: More focus is needed on risk factor management and CHD symptom presentation in women. An emphasis on the chronic disease aspect of CHD may promote a timely focus on secondary prevention and the follow-up needed through patient education and empowerment. RELEVANCE TO CLINICAL PRACTICE: This study demonstrates that primary and secondary prevention education initiatives are needed for CHD risk factor management and symptom interpretation. The implications of smoking on cardiovascular health need further dissemination. Efforts to support smoking cessation need to be strengthened and widely accessible. Primary care can have a key role to play in managing CHD risk and supporting women with positive risk factors.

The universal, collaborative and dynamic model of specialist and advanced nursing and midwifery practice: A way forward?

AIMS AND OBJECTIVES: To inform and guide the development of a future model of specialist and advanced nursing and midwifery practice. BACKGROUND: There is a sizable body of empirical literature supporting the unique contributions of specialist and advanced practice roles to health care. However, there is very little international evidence to inform the integration of a future model for advanced or specialist practice in the Irish healthcare system. DESIGN: A qualitative study was conducted to initiate this important area of inquiry. METHODS: Purposive sampling was used to generate a sample of informants (n = 15) for the interviews. Nurses and midwives working in specialist and advanced practice and participants from other areas such as legislative, regulatory, policy, medicine and education were included in the sampling frame. RESULTS: Arguments for a new model of specialist and advanced practice were voiced. A number of participants proposed that flexibility within specialist and advanced practitioner career pathways was essential. Otherwise, there existed the possibility of being directed into specialised "silos," precluding movement to another area of integrated practice. Future specialist and advanced practice education programmes need to include topics such as the development of emotional and political intelligence. CONCLUSION: The contribution of specialist and advanced practice roles to the health service includes providing rapid access to care, seamless patient flow across services, early discharge and lead coordinator of the patient's care trajectory. There was a recommendation of moving towards a universal model to cultivate specialist and advanced nurse and midwife practitioners. RELEVANCE TO CLINICAL PRACTICE: The model design has Universal application in a range of contexts "U." It is Collaborative in its inclusivity of all key stakeholders "C." The model is Dynamic pertinent to accommodating movement of nurses and midwives across health continua rather than plateauing in very specialised "silos" "D."

Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers.

AIMS AND OBJECTIVES: To collate, synthesise and discuss published evidence and expert professional opinion on enablers and barriers to the development and sustainability of specialist and advanced practice roles in nursing and midwifery. BACKGROUND: Expanded practice is a response to population health needs, healthcare costs and practitioners' willingness to expand their scope of practice through enhanced responsibility, accountability and professional autonomy. DESIGN: This discursive paper is based on a rapid review of literature on enablers and barriers to the development and sustainability of specialist and advanced practice roles and is part of a wider policy analysis. METHODS: We analysed and synthesised of 36 research articles, reviews and discussion papers on enablers and barriers in the development and sustainability of expanded practice roles. RESULTS: Several factors enable role expansion, including: role clarity; credentialing and endorsement; availability of education for expanded roles; individual practitioners' dispositions towards role expansion; support from peers, other professionals and the work organisation; and costs. Where limited or absent, these same factors can constrain role expansion. CONCLUSIONS: Enabling nurses and midwives to practice to their full scope of education and expertise is a global challenge for disciplinary leadership, a national challenge for professional regulation and a local challenge for employers and individual clinicians. These challenges need to be addressed through multistakeholder coordinated efforts at these four levels. RELEVANCE TO CLINICAL PRACTICE: This discursive paper synthesises empirical evidence and expert professional opinion on the factors that enable or hinder the development and sustainability of specialist and advanced practice roles. Providing a critical appraisal of current knowledge, it provides a reference source for disciplinary debate and policy development regarding the nursing and midwifery resource and informs clinicians of the myriad issues that can impact on their capacity to expand their scope of practice.

The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization.

Clinical pathways are known to improve the value of health care in medical and surgical settings but have been rarely studied in the psychiatric setting. This study examined the association between level of adherence to an adolescent depressive disorders inpatient clinical pathway and length of stay (LOS), cost, and readmissions. Patients in the high adherence category had significantly longer LOS and higher costs compared to the low adherence category. There was no difference in the odds of 30-day emergency department return visits or readmissions. Understanding which care processes within the pathway are most cost-effective for improving patient-centered outcomes requires further investigation.

Caring for Children with Medical Complexity: Perspectives of Primary Care Providers.

OBJECTIVE: To describe typical care experiences and key barriers and facilitators to caring for children with medical complexity (CMC) from the perspective of community primary care providers (PCPs). STUDY DESIGN: PCPs participating in a randomized controlled trial of a care-coordination intervention for CMC were sent a 1-time cross-sectional survey that asked PCPs to (1) describe their experiences with caring for CMC; (2) identify key barriers affecting their ability to care for CMC; and (3) prioritize facilitators enhancing their ability to provide care coordination for CMC. PCP and practice demographics also were collected. RESULTS: One hundred thirteen of 155 PCPs sent the survey responded fully (completion rate = 73%). PCPs endorsed that medical characteristics such as polypharmacy (88%), multiorgan system involvement (84%), and rare/unfamiliar diagnoses (83%) negatively affected care. Caregivers with high needs (88%), limited time with patients and caregivers (81%), and having a large number of specialists involved in care (79%) were also frequently cited. Most commonly endorsed strategies to improve care coordination included more time with patients/caregivers (84%), summative action plans (83%), and facilitated communication (eg, e-mail, phone meetings) with specialists (83%). CONCLUSIONS: Community PCPs prioritized more time with patients and their families, better communication with specialists, and summative action plans to improve care coordination for this vulnerable population. Although this study evaluated perceptions rather than actual performance, it provides insights to improve understanding of which barriers and facilitators ideally might be targeted first for care delivery redesign.

Using rapid reviews: an example from a study conducted to inform policy-making.

AIM: A discussion of the potential use of rapid review approaches in nursing and midwifery research which presents a worked example from a study conducted to inform policy decision-making. BACKGROUND: Rapid reviews, which can be defined as outputs of a knowledge synthesis approach that involves modifying or omitting elements of a systematic review process due to limited time or resources, are becoming increasingly popular in health research. This paper provides guidance on how a rapid review can be undertaken and discusses the strengths and challenges of the approach. DESIGN: Data from a rapid review of the literature undertaken in 2015 is used as a worked example to highlight one method of undertaking a rapid review. IMPLICATIONS FOR NURSING: Seeking evidence to inform health policy-making or evidence based practice is a process that can be limited by time constraints, making it difficult to conduct comprehensive systematic reviews. Rapid reviews provide a solution as they are a systematic method of synthesizing evidence quickly. CONCLUSIONS: There is no single best way to conduct a rapid review but researchers can ensure they are adhering to best practice by being systematic, having subject and methodological expertise on the review team, reporting the details of the approach they took, highlighting the limitations of the approach, engaging in good evidence synthesis and communicating regularly with end users, other team members and experts.

The perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners.

AIM: To explore the perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners. BACKGROUND: There is evidence that the contribution of these roles to patient care is poorly understood. DESIGN: This research took place over 2 months in 2015 and is part of a larger study involving a rapid review to inform policy development on the specialist and advanced nursing and midwifery practice in Ireland. As an added value, a qualitative element involving thematic analysis was undertaken with key stakeholders. METHODS: A phenomenological qualitative study was conducted incorporating semi-structured interviews with key stakeholders (n = 15). Purposive sampling with maximum diversity was used to recruit a wide range of perspectives. FINDINGS: Participant's perspectives led to seven themes: Impact of these roles; role preparation, experience and organizational support; specialist and advanced practice roles in an interdisciplinary context; different folks but not such different roles; impact of specialist and advanced practice roles on patient outcomes; barriers and facilitators to enacting specialist and advanced practice roles; future development of these roles. CONCLUSION: There is acknowledgement of the positive impact of specialist and advanced practitioners; however, the evidence is currently not conclusive. Preparation for these roles needs to reflect changes in the calibre of today's professional applicants, and organizational support is paramount to their successful execution. The contribution of their activity to patient outcome needs to be made visible to enhance these roles and to justify the development of new roles across a variety of healthcare areas.

'Betwixt and between health and illness' - women's narratives following acute coronary syndrome.

AIMS AND OBJECTIVES: This study investigated experiences of women with a primary diagnosis of ACS (NSTEMI and Unstable Angina) in the 6-8 week period following discharge from hospital. The aim was to report the experience of the mediating impact of a newly-diagnosed disease. BACKGROUND: Cardiovascular disease is the main cause of mortality in women. Treatment modalities have improved health outcomes and survival rates, however, quality of life and ongoing morbidity after discharge is not clearly understood from a gender specific perspective. DESIGN: A naturalistic case study design guided this study. METHODS: Thirty women participated (n = 30); a within-case followed by a cross-case analysis provided meticulous knowledge of each case. Data collection included participant diaries and face to face interviews. Data were analysed using modified analytic induction which allowed the emergence of theoretical insights. The theoretical concepts, liminality and transitioning were used to inform the analysis. Within-methods triangulation captured the depth and breadth of the women's experiences. RESULTS: The data provide an insight into women's experiences following ACS and highlight a need for support structures and services after discharge. Many women reported a period of disrupted normality following discharge from hospital. While a number of women had transitioned towards recovery, many remained in a liminal space 'betwixt and between' health and illness. Cardiac rehabilitation was reported as a positive experience for those who were attending. CONCLUSIONS: The findings provide a platform for a wider discourse on the needs of women with ACS in the immediate period after discharge from hospital. Women may benefit from gender-specific, appropriately timed, and targeted interventions to facilitate recovery and adaptation to living with CHD. RELEVANCE TO CLINICAL PRACTICE: It is essential that secondary prevention services are modelled and tailored to meet the needs of women and evaluated appropriately to ensure positive outcomes. Nursing could have a key role to play in managing and providing this support.

Multiparameter analysis of stimulated human peripheral blood mononuclear cells: A comparison of mass and fluorescence cytometry.

Mass and fluorescence cytometry are quantitative single cell flow cytometry approaches that are powerful tools for characterizing diverse tissues and cellular systems. Here mass cytometry was directly compared with fluorescence cytometry by studying phenotypes of healthy human peripheral blood mononuclear cells (PBMC) in the context of superantigen stimulation. One mass cytometry panel and five fluorescence cytometry panels were used to measure 20 well-established lymphocyte markers of memory and activation. Comparable frequencies of both common and rare cell subpopulations were observed with fluorescence and mass cytometry using biaxial gating. The unsupervised high-dimensional analysis tool viSNE was then used to analyze data sets generated from both mass and fluorescence cytometry. viSNE analysis effectively characterized PBMC using eight features per cell and identified similar frequencies of activated CD4+ T cells with both technologies. These results suggest combinations of unsupervised analysis programs and extended multiparameter cytometry will be indispensable tools for detecting perturbations in protein expression in both health and disease.

Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals.

OBJECTIVES: To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals. STUDY DESIGN: Multicenter retrospective cohort analysis of 12,449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals. RESULTS: In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥ 12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively. CONCLUSIONS: Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

Construct Validity and Responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales and Infant Scales in the PICU.

OBJECTIVES: To assess the construct validity and the responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales and Infant Scales in the medical-surgical (PICU) and cardiac PICU. DESIGN/SETTING/PARTICIPANTS: Prospective cohort study of 367 inpatients admitted either to the PICU or the cardiac ICU at Seattle Children's Hospital from January 2012 to June 2013. Parent/caregiver and child (≥ 8 yr old, developmentally appropriate, and critical illness resolved) Pediatric Quality of Life Inventory scores were obtained within 24 hours of PICU/cardiac ICU discharge and subsequently at 4-12 weeks following hospital discharge. Of the 491 eligible participants invited to participate, 367 (74.7% response rate) completed the Pediatric Quality of Life Inventory survey at ICU discharge, and of these, 263 (71.7% follow-up response rate) completed the follow-up survey 4-12 weeks after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Responsiveness was assessed by calculating improvement scores (difference between follow-up and ICU discharge scores, Δ Pediatric Quality of Life Inventory). Construct validity was examined by comparing mean improvement scores for known groups differing by medical complexity. At follow-up, [INCREMENT] Pediatric Quality of Life Inventory scores were as follows (mean ± SD): physical domain, 34.8 ± 32.0; and psychosocial domain, 23.1 ± 23.5. Patients with complex chronic or noncomplex chronic disease had physical functioning improvement scores that were 17.4 points (95% CI, -28.3 to -6.5; p < 0.001) and 19.5 points (95% CI, -30.4 to -8.5; p < 0.002) lower than children with no chronic illness, respectively. Patients with complex chronic disease exhibited psychosocial improvement scores that were 9.6 points (95% CI, -18.4 to -0.8; p < 0.033) lower than patients without chronic disease. Patients with noncomplex chronic disease had similar psychosocial improvement scores when compared with patients without chronic disease. CONCLUSIONS: As a measure of health-related quality of live, Pediatric Quality of Life Inventory demonstrated responsiveness and construct validity in a broad population of critically ill children. This measure represents a patient-centered clinically meaningful patient-or-parent-reported outcome measure for pediatric research assessing the clinical effectiveness of PICU/cardiac ICU interventions. When using health-related quality of life recovery as an outcome measure to assess clinical effectiveness in the PICU/cardiac ICU setting, measuring and controlling for the level of medical complexity is important in order to understand the true impact of clinical interventions.