Mast cell-derived chymases are essential for the resolution of inflammatory pain in mice.

Immune cells play a critical role in the transition from acute to chronic pain. However, the role of mast cells in pain remains under-investigated. Here, we demonstrated that the resolution of inflammatory pain is markedly delayed in mast-cell-deficient mice. In response to Complete Freund Adjuvant (CFA), mast-cell-deficient mice showed greater levels of nitric oxide and altered cytokine/chemokine profile in inflamed skin in both sexes. In Wild-Type (WT) mice, the number of mast cell and mast cell-derived chymases; chymase 1 (CMA1) and mast cell protease 4 (MCPT4) increased in the inflamed skin. Inhibiting chymase enzymatic activity delayed the resolution of inflammatory pain. Consistently, local pharmacological administration of recombinant CMA1 and MCPT4 promoted the resolution of pain hypersensitivity and attenuated the upregulation of cytokines and chemokines under inflammation. We identified CCL9 as a target of MCPT4. Inhibition of CCL9 promoted recruitment of CD206 + myeloid cells and alleviated inflammatory pain. Our work reveals a new role of mast cell-derived chymases in preventing the transition from acute to chronic pain and suggests new therapeutic avenues for the treatment of inflammatory pain. Summary: Mast cell-derived chymases play an unexpected role in the resolution of inflammatory pain and regulate the immune response.

Incorporating the Voice of Community Based Pediatricians to Improve Discharge Communication.

INTRODUCTION: Communication between pediatric hospitalists and primary care physicians (PCPs) at discharge is an essential part of a successful transition to home. While many hospitals require communicating with PCPs for all admitted patients, it is unknown if PCPs find such communication valuable or if it improves outcomes. Our global aim was to improve discharge communication for patients that pediatric hospitalists and PCPs deemed appropriate. METHODS: We sent surveys to 422 outpatient pediatricians in our care network to understand their communication preferences. Survey results informed local guidelines for when hospitalists should directly contact PCPs. We determined the proportion of inpatient discharges meeting those guidelines and set a target for our primary process metric: the proportion of discharges with attempted direct PCP contact. We engaged in Plan-Do-Study-Act cycles, including a discharge documentation tool in the electronic health record, education of inpatient teams, email reminders including group performance data, asynchronous Health Insurance Portability and Accountability Act-compliant messaging application, and competitions that shared blinded individual data. RESULTS: We increased the percentage of documented direct communication with the PCPs from 2% to 33% and from 4% to 65% for those who met guidelines for direct communication. CONCLUSIONS: PCPs only want direct communication on a subset of discharges. Interventions focused on high-yield populations improved discharge communication in our institution.

Hospital Charges Associated with Central Venous Stenosis in Pediatric Patients Requiring Long-Term Central Venous Access.

OBJECTIVE: To evaluate the hospital charges associated with central venous stenosis in pediatric patients requiring long-term central venous catheters, via associated charges and hospital length of stay (LOS). STUDY DESIGN: This institutional review board-approved retrospective review identified pediatric patients with central venous catheters and either short bowel syndrome (SBS) or end-stage renal disease (ESRD) diagnosed between 2008 and 2015 using the Pediatric Health Information System. These 2 cohorts were selected because long-term central venous access is commonly required for survival. Prevalence of central venous stenosis, total number of admissions, procedures, LOS, and associated charges were recorded. Statistical analysis performed with Wilcoxon nonparametric and 2-sample t test with a significance of P < .05. RESULTS: Of 4952 patients with SBS and 4665 patients with ESRD, 169 (3.4%) patients with SBS and 191 (4.1%) patients with ESRD were diagnosed with central venous stenosis (360 patients total [3.7%]). The cumulative median admissions and LOS was higher in patients with SBS with central venous stenosis (15 admissions and 156 days) vs those without central venous stenosis (5 admissions and 110 days) (P < .001). The cumulative median number of admissions and LOS was higher in patients with ESRD with central venous stenosis (13 admissions and 72 days) vs those without central venous stenosis (7 admissions and 42 days) (P < .001). The mean cumulative charges for patients with SBS with central venous stenosis were higher than for those without central venous stenosis ($1.89 million vs $1.11 million, respectively) (P < .001). Similarly, the mean cumulative charges for patients with ESRD with central venous stenosis were higher than for those without central venous stenosis ($1.17 millions vs $702 000, respectively) (P < .001). CONCLUSIONS: Pediatric patients with central venous stenosis have significantly higher total charges, imaging charges, number of admissions, and longer LOS. Attention to mitigate the incidence of central venous stenosis in pediatric patients requiring long-term central venous access is warranted.

Opioid utilization is minimal after outpatient pediatric urologic surgery.

INTRODUCTION: There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution. MATERIALS AND METHODS: After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use. RESULTS: Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups. DISCUSSION AND CONCLUSIONS: Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.

OBJECTIVE: This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. METHODS: We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. RESULTS: For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. CONCLUSION: A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.