ABSTRACT
Background Blood product ordering is a complex process, and mistakes can lead to patient harm and poor outcomes. Orders and order sets can be designed to help mitigate errors, but major changes in design can unintentionally cause new errors. Objectives (1) Utilize formative in situ usability testing to iteratively improve the design of a redesigned blood product order set prior to go-live, (2) implement changes based on feedback derived from this testing, and (3) Compare the error rate, System Usability Scale (SUS) score, time to task completion, and click counts between the prior order set in use at the time and the revised redesigned order set. Methods A multidisciplinary project team convened to redesign blood product orders and order sets from scratch based on a review of literature and benchmarking against four pediatric academic institutions with the goal of addressing prior ordering errors. The new redesigned blood product order set was iteratively updated via in situ formative usability testing performed with available clinical users using a concurrent think-aloud protocol in real clinical environments. Errors, SUS scores, time to task completion, and click counts were assessed for the revised redesigned order set using summative testing. Results Formative usability testing with 20 participants led to seven design changes in the redesigned order set which reduced the error rate at go-live. Summative usability testing showed that even though the usability scores were only slightly improved for the revised redesigned order set, the error rates in blood orders were significantly decreased. Conclusion Usability testing can identify design errors early in the process which can be rectified prior to implementation, thus avoiding unintended consequences of changes.
ABSTRACT
Diffuse midline gliomas are among the deadliest human cancers and have had little progress in treatment in the last 50 years. Cell cultures of these tumors have been developed recently, but the degree to which such cultures retain the characteristics of the source tumors is unknown. DNA methylation profiling offers a powerful tool to look at genome-wide epigenetic changes that are biologically meaningful and can help assess the similarity of cultured tumor cells to their in vivo progenitors. Paraffinized diagnostic tissue from three diffuse intrinsic pontine gliomas with H3 K27M mutations was compared with subsequent passages of neurosphere cell cultures from those tumors. Each cell line was passaged 3-4 times and analyzed with DNA methylation arrays and standard algorithms that provided a comparison of diagnostic classification and cluster analysis. All samples tested maintained high classifier scores and clustered within the reference group of H3 K27M-mutant diffuse midline gliomas. There was a gain of 1q in all cell lines, with two cell lines initially manifesting the gain of 1q only during culture. In vitro cell cultures of H3 K27M-mutant gliomas maintain high degrees of similarity in DNA methylation profiles to their source tumor, confirming their fidelity even with some chromosomal changes.
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BACKGROUND: DICER1 mutations, though infrequent, are encountered on preoperative molecular testing of indeterminate adult and pediatric thyroid fine-needle aspiration (FNA) specimens. Yet, published cytomorphologic features of DICER1-altered thyroid lesions are limited. Cytomorphological features of DICER1-altered thyroid lesions were examined in a multipractice FNA cohort with clinical, radiological, and histologic data. METHODS: The cohort comprised 18 DICER1-altered thyroid FNAs, with 14 having slides available and eight having corresponding surgical resections. Smears, ThinPrep, and formalin-fixed cell block slides were reviewed and correlated with histology, when available. Clinical and radiologic data were obtained from the medical record. RESULTS: Most DICER1-altered FNAs were classified as atypia of undetermined significance (94.4%). DICER1 mutations occurred in codons 1709 (50%), 1810 (27.8%), and 1813 (22.2%). One patient had an additional DICER1 p.D1822N variant in both of their FNAs. Lesions were often hypoechoic (35.3%) and solid (47.1%) on ultrasound. Notable cytomorphologic features include mixed but prominent microfollicular or crowded component, variable colloid, and insignificant nuclear atypia. On resection (n = 10), histologic diagnoses ranged from benign follicular adenoma and low-risk follicular thyroid carcinoma to high-grade follicular-derived nonanaplastic thyroid carcinoma. Subcapsular infarct-type change was the most common histologic change. There was no evidence of recurrence or metastasis in eight patients on limited follow-up. CONCLUSION: DICER1-altered thyroid lesions occurred frequently in young females and FNAs show RAS-like cytomorphology including crowded, mixed macro-/microfollicular pattern, and bland nuclear features. On resection, DICER1-altered thyroid lesions include benign (50%), low-risk lesions (30%), or high-risk malignancies (20%).
Subject(s)
DEAD-box RNA Helicases , Mutation , Ribonuclease III , Thyroid Neoplasms , Humans , Ribonuclease III/genetics , DEAD-box RNA Helicases/genetics , Female , Thyroid Neoplasms/genetics , Thyroid Neoplasms/pathology , Male , Biopsy, Fine-Needle , Adult , Middle Aged , Aged , Adenocarcinoma, Follicular/genetics , Adenocarcinoma, Follicular/pathology , Adolescent , Child , Young Adult , Thyroid Nodule/genetics , Thyroid Nodule/pathology , Thyroid Gland/pathology , Thyroid Gland/surgery , Thyroid Gland/diagnostic imaging , Carcinoma, Papillary/genetics , Carcinoma, Papillary/pathology , Carcinoma, Papillary/surgeryABSTRACT
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is prevalent in the African American population. We identified eighteen G6PD-deficient samples (9%) in a study of residual, de-identified whole blood specimens from 200 African American pediatric patients using a point-of-care instrument. This highlights the possibility of a rapid time to result for G6PD testing, which can be valuable in some clinical scenarios.
ABSTRACT
INTRODUCTION: The absence of submucosal ganglion cells does not reliably distinguish Hirschsprung disease from non Hirschsprung disease in anorectal line biopsies. Calretinin staining might be helpful in these biopsies. To determine its value, we analyzed calretinin positive mucosal neurites in anorectal line biopsies. METHODS: Two pediatric pathologists, without access to patient data, evaluated calretinin positive mucosal neurites in anorectal line junctional mucosa in archival rectal biopsies contributed by 17 institutions. A separate investigator compiled patient information and sent data for statistical analysis. RESULTS: Biopsies with anorectal junctional mucosa from 115 patients were evaluated for calretinin positive mucosal neurites. 20/20 Hirschsprung disease biopsies were negative. 87/88 non Hirschsprung disease biopsies and 7/7 post pullthrough Hirschsprung disease neorectal biopsies were positive. Statistical analysis of the 108 non pullthrough biopsies yielded an accuracy of 99.1% (sensitivity 100%, specificity 98.9%). Age range was preterm to 16 years. Biopsy size was less than 1 mm to over 1 cm. CONCLUSIONS: Absence of calretinin positive mucosal neurites at the anorectal line was highly accurate in distinguishing Hirschsprung disease from non Hirschsprung disease cases in this blinded retrospective study. Calretinin staining is useful for interpreting biopsies from the physiologic hypoganglionic zone up to the anorectal line.
Subject(s)
Hirschsprung Disease , Infant, Newborn , Child , Humans , Infant , Adolescent , Retrospective Studies , Immunohistochemistry , Calbindin 2 , Hirschsprung Disease/diagnosis , Hirschsprung Disease/pathology , Biopsy , Rectum/pathologyABSTRACT
BACKGROUND: Geriatrics research generally cumulates in academic journal publications, with variable diffusion to patients and communities. PlanYourLifespan.org is a free, evidence-based tool that assists older adults, and their loved ones, to better understand and plan for their long-term support needs. There is a need to effectively disseminate geriatrics research, such as PlanYourLifespan.org, to communities that may directly benefit from this research. OBJECTIVE: To leverage community-based stakeholder leaders, utilizing a train-the-trainer program, to disseminate PlanYourLifespan.org and evaluate the extent of the dissemination. METHODS: Using a train-the-trainer strategy, community stakeholder leaders from the original study paired up with newly recruited community stakeholder leaders. New community stakeholder leaders were trained on dissemination, using a "how-to-disseminate" web-based toolkit-developed as part of this project. Newly trained community stakeholder leaders subsequently trained additional community stakeholder leaders who conducted and tracked dissemination activities in their communities. Google Analytics tracked newly created PlanYourLifespan.org accounts, login sessions, and daily website visitors. RESULTS: Five newly trained community stakeholder leaders disseminated PlanYourLifespan.org over a three-month period. Cumulatively, on the day of the dissemination activity, there were 11,361 PlanYourLifespan.org log-ins (average: 378.7 log-ins/activity day), 89,068 log-ins (average: 2969 log-ins/activity week) one-week after the activity, and 319,154 log-ins (average: 10,638 log-ins/activity month) one month after the dissemination activity. Approximately 9.4 new PlanYourLifespan.org accounts were created one-week post dissemination activity and over 1100 new accounts in the one-month period thereafter. CONCLUSIONS: Wide dissemination of PlanYourLifespan.org occurred by leveraging a train-the-trainer approach with community stakeholder leaders. Researchers should consider collaborating early on with community stakeholders to meaningfully disseminate results.
Subject(s)
Long-Term Care , Humans , AgedABSTRACT
CONTEXT.: Diagnostic testing for SARS-CoV-2 in symptomatic and asymptomatic children remains integral to care, particularly for supporting return to and attendance in schools. The concordance of SARS-CoV-2 detection in children, using various specimen types, has not been widely studied. OBJECTIVE.: To compare 3 sample types for SARS-CoV-2 polymerase chain reaction (PCR) testing in children, collected and tested at a single facility. DESIGN.: We prospectively recruited 142 symptomatic and asymptomatic children/young adults into a sample comparison study performed in a single health care system. Each child provided self-collected saliva, and a trained health care provider collected a mid-turbinate nasal swab and nasopharyngeal (NP) swab. Specimens were assayed within 24 hours of collection by using reverse transcription-polymerase chain reaction (RT-PCR) to detect SARS-CoV-2 on a single testing platform. RESULTS.: Concurrently collected saliva and mid-turbinate swabs had greater than 95% positive agreement with NP swabs when obtained within 10 days of symptom onset. Positive agreement of saliva and mid-turbinate samples collected from children with symptom onset >10 days prior, or without symptoms, was 82% compared to NP swab samples. Cycle threshold (Ct) values for mid-turbinate nasal samples more closely correlated with Ct values from NP samples than from saliva samples. CONCLUSIONS.: These findings suggest that all 3 sample types from children are useful for SARS-CoV-2 diagnostic testing by RT-PCR, and that concordance is greatest when the child has had symptoms of COVID-19 within the past 10 days. This study provides scientific justification for using sample types other than the NP swab for SARS-CoV-2 testing in pediatric populations.
Subject(s)
COVID-19 , SARS-CoV-2 , COVID-19/diagnosis , COVID-19 Testing , Child , Humans , Nasopharynx , Outpatients , Polymerase Chain Reaction , Reverse Transcriptase Polymerase Chain Reaction , Reverse Transcription , SARS-CoV-2/genetics , Saliva , Specimen Handling/methods , Turbinates , Young AdultABSTRACT
Researchers and patients conducted an environmental scan of policy documents and public-facing websites and abstracted data to describe COVID-19 adult inpatient visitor restrictions at 70 academic medical centers. We identified variations in how centers described and operationalized visitor policies. Then, we used the nominal group technique process to identify patient-centered information gaps in visitor policies and provide key recommendations for improvement. Recommendations were categorized into the following domains: 1) provision of comprehensive, consistent, and clear information; 2) accessible information for patients with limited English proficiency and health literacy; 3) COVID-19 related considerations; and 4) care team member methods of communication.
ABSTRACT
Among symptomatic outpatients, subgenomic RNA of severe acute respiratory syndrome coronavirus 2 in nasal midturbinate swab specimens was concordant with antigen detection but remained detectable in 13 (82.1%) of 16 nasopharyngeal swab specimens from antigen-negative persons. Subgenomic RNA in midturbinate swab specimens might be useful for routine diagnostics to identify active virus replication.
Subject(s)
COVID-19 , SARS-CoV-2 , Diagnostic Tests, Routine , Humans , Nasopharynx , RNAABSTRACT
BACKGROUND: Absent submucosal ganglion cells in biopsies 1-3 cm above the pectinate line establishes the pathologic diagnosis of Hirschsprung Disease (HD). Calretinin stains both ganglion cells and their mucosal neurites and has gained importance in HD diagnosis. Absent calretinin positive mucosal neurites in biopsies at the appropriate level above the pectinate line is highly specific for HD. Whether this applies to lower biopsies is uncertain. To address this, we studied anorectal canal autopsy specimens from infants. METHODS: We performed an autopsy study of infant anorectal canal specimens to describe calretinin staining in this region. Calretinin staining was correlated with histologic and gross landmarks. RESULTS: In all 15 non-HD specimens, calretinin positive mucosal neurites were present in glandular mucosa up to the anorectal line where neurites rapidly diminished. Age range was preterm 26 weeks to 3 months. CONCLUSIONS: Calretinin positive mucosal neurites are present in glandular mucosa up to the anorectal line in young infants. This is potentially important regarding neonatal HD biopsy level and diagnosis. Positive calretinin staining at the anorectal line favors normal innervation making HD unlikely. Absent calretinin positive neurites in glandular mucosa is worrisome for HD in young infants, regardless of location.
Subject(s)
Hirschsprung Disease , Rectum , Autopsy , Biopsy , Calbindin 2 , Humans , Immunohistochemistry , Infant , Infant, NewbornABSTRACT
While there has been significant progress in the development of rapid COVID-19 diagnostics, as the pandemic unfolds, new challenges have emerged, including whether these technologies can reliably detect the more infectious variants of concern and be viably deployed in non-clinical settings as "self-tests". Multidisciplinary evaluation of the Abbott BinaxNOW COVID-19 Ag Card (BinaxNOW, a widely used rapid antigen test, included limit of detection, variant detection, test performance across different age-groups, and usability with self/caregiver-administration. While BinaxNOW detected the highly infectious variants, B.1.1.7 (Alpha) first identified in the UK, B.1.351 (Beta) first identified in South Africa, P.1 (Gamma) first identified in Brazil, B.1.617.2 (Delta) first identified in India and B.1.2, a non-VOC, test sensitivity decreased with decreasing viral loads. Moreover, BinaxNOW sensitivity trended lower when devices were performed by patients/caregivers themselves compared to trained clinical staff, despite universally high usability assessments following self/caregiver-administration among different age groups. Overall, these data indicate that while BinaxNOW accurately detects the new viral variants, as rapid COVID-19 tests enter the home, their already lower sensitivities compared to RT-PCR may decrease even more due to user error.
Subject(s)
COVID-19 Serological Testing , COVID-19/diagnosis , Point-of-Care Systems , Self-Testing , Humans , Limit of Detection , SARS-CoV-2 , Sensitivity and SpecificityABSTRACT
Faced with the COVID-19 pandemic, the US system for developing and testing technologies was challenged in unparalleled ways. This article describes the multi-institutional, transdisciplinary team of the "RADxSM Tech Test Verification Core" and its role in expediting evaluations of COVID-19 testing devices. Expertise related to aspects of diagnostic testing was coordinated to evaluate testing devices with the goal of significantly expanding the ability to mass screen Americans to preserve lives and facilitate the safe return to work and school. Focal points included: laboratory and clinical device evaluation of the limit of viral detection, sensitivity, and specificity of devices in controlled and community settings; regulatory expertise to provide focused attention to barriers to device approval and distribution; usability testing from the perspective of patients and those using the tests to identify and overcome device limitations, and engineering assessment to evaluate robustness of design including human factors, manufacturability, and scalability.
ABSTRACT
Placental infection by SARS-CoV-2 with various pathologic alterations reported. Inflammatory findings, such as extensive perivillous fibrin deposition and intervillous histiocytosis, have been postulated as risk factors for fetal infection by SARS-CoV-2. We describe the placental findings in a case of a 31-year-old mother with SARS-CoV-2 infection who delivered a preterm female neonate who tested negative for SAR-CoV2 infection. Placental examination demonstrated a small for gestational age placenta with extensive intervillous histiocytosis, syncytiotrophoblast karyorrhexis, and diffuse intervillous fibrin deposition. Immunohistochemical staining demonstrated infection of the syncytiotrophoblasts by SARS-CoV-2 inversely related to the presence of intervillous histiocytes and fibrin deposition. Our case demonstrates that despite extensive placental pathology, no fetal transmission of SARS-CoV-2 occurred, as well as postulates a relationship between placental infection, inflammation, and fibrin deposition.
Subject(s)
COVID-19/transmission , Fibrin/metabolism , Histiocytosis/pathology , Pregnancy Complications, Infectious/pathology , SARS-CoV-2/physiology , Adult , COVID-19/virology , Female , Histiocytosis/virology , Humans , Immunohistochemistry , Infant, Newborn , Placenta/pathology , Placenta/virology , Pregnancy , Pregnancy Complications, Infectious/virology , Trophoblasts/pathology , Trophoblasts/virologyABSTRACT
BACKGROUND: SARS-CoV-2 infection in children does not seem to follow the same pattern as in adults. Limited information is published on the level of antibody production and the duration of antibody response in children with COVID-19. Moreover, it is unknown if all children have a similar immune response to the infection, or if there are age dependent differences. In these data, we look at the IgM and IgG levels and duration of two age groups infected by the SARS-CoV-2 virus. METHODS: Residual laboratory specimens from pediatric patients positive for SARS-CoV-2 infection were tested for IgM and IgG against SARS-CoV-2 using an automated Abbott ARCHITECT i1000. We tested 181 specimens from 41 patients with a positive molecular result. Data was grouped either as time after nucleic acid amplification test (NAAT) or time after symptom onset. Patient samples were divided into 2 age groups: 0 to 11 years old and 12 to 19 years old. The assays detect IgM against the spike protein and IgG against the nucleocapsid protein.
Subject(s)
COVID-19 Testing , COVID-19/diagnosis , Health Services Accessibility , Pandemics , SARS-CoV-2/isolation & purification , Antigens, Viral/analysis , Antigens, Viral/immunology , COVID-19/epidemiology , COVID-19 Nucleic Acid Testing , COVID-19 Testing/economics , COVID-19 Testing/methods , COVID-19 Testing/statistics & numerical data , Coronavirus Nucleocapsid Proteins/analysis , Coronavirus Nucleocapsid Proteins/immunology , Cost-Benefit Analysis , Evaluation Studies as Topic , Financing, Government , Humans , Inventions , National Institutes of Health (U.S.) , Point-of-Care Testing , Public-Private Sector Partnerships/organization & administration , RNA, Viral/analysis , Reagent Kits, Diagnostic/supply & distribution , SARS-CoV-2/immunology , Sensitivity and Specificity , Spike Glycoprotein, Coronavirus/analysis , Spike Glycoprotein, Coronavirus/immunology , United States/epidemiologyABSTRACT
BACKGROUND: Clinical laboratory testing has been an essential part of COVID-19 management. Serology can provide valuable information regarding a patient's exposure to virus, and may have a larger role to play as vaccines becomes available. Limited data is available on the serological response in pediatric patients. Here we investigate the use of one manufacturer's commercial assays for detecting IgM and IgG in an exclusively pediatric population. METHODS: Abbott SARS-CoV-2 IgM and IgG assays were performed on an Abbott ARCHITECT i1000. For specificity studies, we tested 78 patient specimens collected before the COVID-19 pandemic, and 66 specimens from patients who tested negative for SARS-CoV-2 nucleic acid amplification test (NAAT) during the COVID-19 pandemic. For sensitivity we tested 181 specimens from 41 patients with a positive NAAT result. Precision data was acquired for 20 days. RESULTS: For IgM, the highest qualitative positive agreement with molecular results was observed to be 15-30 days after a positive NAAT result or after symptom onset. For IgG, the highest positive agreement was 31-60 days after a positive NAAT result or 61-90 days after the start of symptoms. IgM started to decline 30 days after NAAT results and faded by 90 days. IgG started to decrease 60 days after a positive NAAT result. CONCLUSION: The Abbott IgM and IgG assays have negative agreements of 98.7-100% relative to NAAT results. The IgM and IgG levels assayed by these methods start to decline months after positive molecular results and onset of symptoms in a pediatric population.
ABSTRACT
We describe a community-engaged approach to develop and pilot a home care aide (HCA) administered health interview with Medicaid Home and Community-based Services clients. Stakeholders identified five priority health topics and selected a card sorting methodology for interviews. A barrier to interviewing clients was decreased communication skills among HCAs, and we modified health interview training to include communication training. Stakeholders reported the interview methodology was feasible within usual care, acceptable to clients, and contributed to increased knowledge on providing person-centered care. Stakeholder engagement resulted in valuable insights regarding the health interview methodology and relevant training needs.