Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse.

OBJECTIVES: Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis. METHODS: We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process. RESULTS: The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR). CONCLUSIONS: Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning.

Achieving adequate growth in infants with congenital diaphragmatic hernia prior to discharge.

BACKGROUND/PURPOSE: To evaluate the enteral feeding requirements, including caloric provisions, of infants with CDH in relation to growth patterns. METHODS: A retrospective observational study was conducted on infants with CDH between August 2012 and March 2017. Electronic medical records were reviewed to extract detailed infant feeding data and anthropometric measurements at monthly intervals until discharge. Statistical methods of analysis included generalized linear models, Pearson correlation coefficient, Analysis of variance (ANOVA), Kruskal-Wallis, Wilcoxon rank sum, and Fisher's Exact tests. RESULTS: Among 149 infants with CDH, 45% (n = 67) met criteria for malnutrition at discharge. Maternal human milk (HM) was initiated in 95% of infants (n = 142) and continued in 79% of infants (n = 118) at discharge. Overall, 50% received fortification of feeds, including 60% (n = 89) of formula fed infants compared to only 21% (n = 31) of HM fed infants (p<0.001). Infants fed formula had lower weight-for-length z-scores at discharge compared to those fed HM. CONCLUSIONS: Infants receiving HM demonstrated improved growth compared to formula fed infants. However, higher calorie feeding regimens need to be initiated earlier to improve growth velocity. Prompt recognition of malnutrition and growth failure with aggressive supplementation may improve the overall growth of infants with CDH and has the potential to improve long term neurodevelopmental outcomes.

Differences in short-term neonatal outcomes between discordant twins.

PURPOSE: To evaluate short-term outcomes associated with discordant twin pairs admitted to the NICU. DESIGN: A retrospective descriptive study comparing discordant twin pairs. SUBJECTS: Three hundred eighty-four discordant twin pairs were included. Mean gestational age of the twin pairs was 32.6 weeks (range, 24-39). METHODS: The ParadigmHealth database was queried for all twin admissions from January 2001 to June 2004 admitted to 453 NICUs across the United States. Discordance was calculated for each twin set as defined as greater than 20% difference in birth weight. Exclusion criteria were death of a twin, congenital anomalies, or extracorporeal life support. MAIN OUTCOME MEASURES: Demographics, respiratory needs, feeding characteristics, complications, and discharge needs. RESULTS: A total of 384 discordant twin pairs met inclusion criteria. The larger twins required more ventilation/continuous positive airway pressure (55% vs 44%, P < .01) and/or oxygen therapy (50% vs 41%, P = .02) compared with smaller twins. Smaller twins reached full oral (PO) feeds an average of 0.6 weeks later than larger twins (P < .0001) but had more weight gain per day. Smaller twins transitioned to an open crib at lower weights but at slightly greater age. No differences were noted with necrotizing enterocolitis or apnea. Smaller twins had increased nosocomial infections. Mean length of stay was shorter (P = .0036) in the larger twin group. Only 33% of the twin pairs were discharged on the same day. CONCLUSIONS: Larger twins had more acute respiratory issues but achieved certain milestones more rapidly with fewer complications, thus leading to earlier discharge compared with their smaller twin counterparts.

Heliox attenuates lung inflammation and structural alterations in acute lung injury.

Low-density gas mixtures, such as heliox, were shown to reduce the work of breathing and facilitate the distribution of inspired gas. Since supplemental ventilatory and oxygen requirements may lead to pulmonary inflammation and structural alterations, we hypothesized that by reducing these requirements, heliox breathing may attenuate the acute inflammatory and structural changes associated with acute lung injury. Spontaneously breathing neonatal pigs were anesthetized, instrumented, supported with continuous positive airway pressure (CPAP), injured with oleic acid, and randomized to nitrox (n = 6) or heliox (n = 5).F(I)O(2) was titrated for pulse oximetry (SpO(2)) 95 +/- 2% for 4 hr. Gas exchange and pulmonary mechanics were measured. Lungs were analyzed for myeloperoxidase (MPO), interleukin-8 (IL-8), and histomorphometery. Relationships between physiologic indices and cumulative lung structure and inflammatory indices were evaluated. With heliox, compliance was significantly greater, while tidal volume, frequency, minute ventilation, F(I)O(2), arterial carbon dioxide tension (PaCO(2)), MPO, and IL-8 were significantly lower compared to nitrox. The expansion index and number of exchange units were significantly greater with heliox, while the exchange unit area (EUA) was smaller. MPO was significantly and positively correlated with F(I)O(2) (r = 0.76) and EUA (r = 0.63), and negatively correlated with number of open exchange units/field (r = -0.73). Compared to breathing nitrox, these data indicate that heliox improved the distribution of inspired gas, thereby recruiting more gas exchange units, improving gas exchange efficiency, reducing ventilatory and oxygen requirements, and attenuating lung inflammation. These data suggest that heliox breathing may have the combined therapeutic benefits of attenuating lung inflammation by reducing mechanical and oxidative stress in the clinical management of acute lung injury.