Medical Child Welfare Task Force: A Multidisciplinary Approach to Identifying Medical Child Abuse.

Medical child abuse is a complex form of maltreatment with powerful and long-lasting impacts on the overall health of affected children. The complexity of this condition renders it challenging for clinicians to recognize its presence and intervene appropriately. The failure of medical systems to identify and deescalate care in this form of maltreatment can result in grievous patient harm. Although the medical literature provides limited guidance on how to address these multifaceted cases, several studies advocate for a multidisciplinary approach. Following a severe and chronic case of medical child abuse at our institution, deficits in response became clear within our hospital system. In reaction to these gaps, the Medical Child Welfare Task Force was developed to formalize education and multidisciplinary collaboration around medical child abuse. The support of institutional leadership and the involvement of multiple medical disciplines that commonly encounter these patients was vital to the implementation and long-term success of the endeavor. To facilitate case identification, education was provided to clinicians in a variety of forums. Moreover, we leveraged the electronic medical record to streamline our ability to monitor cases of medical child abuse and communicate the concerns and plan of care to other providers, both within and outside of our health system. A postimplementation survey determined that the establishment of a multidisciplinary team increased provider comfort and skill in identifying and managing cases of suspected medical child abuse.

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.

Addressing Environmental Smoke Exposure During Pediatric Hospitalization: Attitudes and Practices of Pediatric Nurses Versus Respiratory Therapists.

BACKGROUND: Tobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting. METHODS: An online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded. RESULTS: A total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002). CONCLUSIONS: Compared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

Spanish Interpreter Services for the Hospitalized Pediatric Patient: Provider and Interpreter Perceptions.

BACKGROUND: Many Americans have limited English proficiency (LEP) and difficulty communicating with health care providers, creating inequitable health care delivery. Despite widespread interpreter availability in hospitals, perceptions of interpreter services in the pediatric inpatient setting are largely unknown. OBJECTIVE: To investigate staff perspectives regarding: 1) roles of the interpreter and provider (attending, resident, and nurse) during an encounter, 2) modalities of interpretation, and 3) barriers to services. METHODS: Focus groups were conducted with: 1) hospital-employed Spanish interpreters, 2) Pediatric Hospital Medicine attendings, 3) pediatric and internal medicine-pediatric residents, and 4) medical unit nurses. Sessions were audio-recorded and transcribed. Using Atlas.ti, 2 investigators created the coding scheme, independently coded the data, and achieved consensus. Qualitative methods were used for thematic analysis. RESULTS: Fourteen groups (n = 59 participants) were held: 3 interpreter groups (n = 10), 3 attending groups (n = 14), 2 resident groups (n = 17), and 6 nurse groups (n = 18). Most believed the interpreter's role was to serve as a conduit (provide word-for-word interpretation), act as a cultural broker, and maintain transparency (not withhold information). All groups felt providers should interact with families as they would with English-speaking families. In-person interpreters were preferred over telephone and video for being more accurate, efficient, and personable. Barriers to accessing services included time needed for interpretation, overconfidence in language skills, variable family dynamics, and identification of LEP families. CONCLUSIONS: In-person interpreters are highly valued, fulfilling complex roles. However, operational and human factors limit access to services in the hospital. These findings, along with family perspectives, can be used to optimize interpretation experiences.

Barriers to Minimizing Respiratory Viral Testing in Bronchiolitis: Physician Perceptions on Testing Practices.

OBJECTIVES: To assess pediatric providers' perceptions on viral testing and to determine barriers to minimizing respiratory viral testing (RVT) in bronchiolitis. METHODS: A single-center, cross-sectional study was conducted and included 6 focus group discussions with pediatric providers. Questions were focused on identifying factors associated with obtaining RVT. Focus group discussions were transcribed verbatim and coded for emergent themes. RESULTS: Clinicians report that they themselves do not typically obtain RVT in otherwise healthy patients with bronchiolitis. The most commonly cited reasons for not obtaining RVT is that it does not aid medical decision-making and that it is used as an educational opportunity for trainees. However, clinicians tend to obtain RVT when they are directed by another clinician, when they desire reassurance, when RVT is perceived as "doing something," and when there are knowledge gaps on institutional cohorting policies. CONCLUSIONS: Clinician medical decision-making is influenced by multiple internal and external factors. Intended behaviors do not always correlate with actual actions because of these influences. Developing interventions in which some of these factors are addressed may help reduce unnecessary RVT among healthy patients with bronchiolitis and could be considered for broader application beyond this patient population.

Methicillin-resistant Staphylococcus aureus as a Cause of Lemierre's Syndrome.

Lemierre's syndrome (LS) or jugular vein suppurative thrombophlebitis is well described in literature. The organisms most often responsible are Fusobacterium necrophorum or anaerobic flora. We present a case of LS with an atypical microbiologic cause, methicillin-resistant Staphylococcus aureus. We also present retrospective review of all LS cases from our institution and identified 2 additional children with LS caused by methicillin-resistant S. aureus.

Peripheral CD8+ T cell tolerance to self-proteins is regulated proximally at the T cell receptor.

CD8(+) T cell tolerance, although essential for preventing autoimmunity, poses substantial obstacles to eliciting immune responses to tumor antigens, which are generally overexpressed normal proteins. Development of effective strategies to overcome tolerance for clinical applications would benefit from elucidation of the immunologic mechanism(s) regulating T cell tolerance to self. To examine how tolerance is maintained in vivo, we engineered dual-T cell receptor (TCR) transgenic mice in which CD8(+) T cells recognize two distinct antigens: a foreign viral-protein and a tolerizing self-tumor protein. Encounter with peripheral self-antigen rendered dual-TCR T cells tolerant to self, but these cells responded normally through the virus-specific TCR. Moreover, proliferation induced by virus rescued function of tolerized self-tumor-reactive TCR, restoring anti-tumor activity. These studies demonstrate that peripheral CD8(+) T cell tolerance to self-proteins can be regulated at the level of the self-reactive TCR complex rather than by central cellular inactivation and suggest an alternate strategy to enhance adoptive T cell immunotherapy.

Interleukin-15 rescues tolerant CD8+ T cells for use in adoptive immunotherapy of established tumors.

CD8+ T cells can mediate eradication of established tumors, and strategies to amplify tumor-reactive T-cell numbers by immunization or ex vivo expansion followed by adoptive transfer are currently being explored in individuals with cancer. Generating effective CD8+ T cell-mediated responses to tumors is often impeded by T-cell tolerance to relevant tumor antigens, as most of these antigens are also expressed in normal tissues. We examined whether such tolerant T cells could be rescued and functionally restored for use in therapy of established tumors. We used a transgenic T-cell receptor (TCR) mouse model in which peripheral CD8+ T cells specific for a candidate tumor antigen also expressed in liver are tolerant, failing to proliferate or secrete interleukin (IL)-2 in response to antigen. Molecular and cellular analysis showed that these tolerant T cells expressed the IL-15 receptor alpha chain, and could be induced to proliferate in vitro in response to exogenous IL-15. Such proliferation abrogated tolerance and the rescued cells became effective in treating leukemia. Therefore, high-affinity CD8+ T cells are not necessarily deleted by encounter with self-antigen in the periphery, and can potentially be rescued and expanded for use in tumor immunotherapy.