Identifying Gender and Racial Bias in Pediatric Fellowship Letters of Recommendation: Do Word Choices Influence Interview Decisions?

OBJECTIVES: To describe linguistic differences in letters of recommendation (LORs) for pediatric fellowship candidates based on applicant and letter writer demographics and to examine if these differences influenced the decision to interview a candidate for a fellowship position. STUDY DESIGN: LORs for applicants to 8 pediatric subspecialty fellowships at a single academic center from the 2020 Match were analyzed in this cross-sectional study. Frequency of validated agentic and communal terms in each letter were determined by a language processing web application. Bias was determined as having a >5% surplus of agentic or communal terms. RESULTS: We analyzed 1521 LORs from 409 applicants: 69% were women, 28% were under-represented minorities in medicine (URM), and 50% were invited to interview. Overall, 66% of LORs were agentic biased, 16% communal biased, and 19% neutral. There was no difference in bias in LORs by an applicant's gender (woman 67% agentic vs man 62% agentic; P = .058), race, or ethnicity (non-URM 65% agentic vs URM 67% agentic; P = .660). Despite a lower frequency of agentic terms in LORs for applicants invited for interviews, when accounting for other components of an application and applicant demographics, no significant association was made between language bias in LORs and fellowship interview status. CONCLUSIONS: The frequency of agentic and communal terms in LORs for pediatric subspecialty fellowship candidates were not found to influence the decision to invite a candidate to interview. However, raising awareness of potential areas of bias within the pediatric fellowship selection process might lead to a more equitable and holistic approach to application review.

Time-resolved turbulent dynamo in a laser plasma.

Understanding magnetic-field generation and amplification in turbulent plasma is essential to account for observations of magnetic fields in the universe. A theoretical framework attributing the origin and sustainment of these fields to the so-called fluctuation dynamo was recently validated by experiments on laser facilities in low-magnetic-Prandtl-number plasmas ([Formula: see text]). However, the same framework proposes that the fluctuation dynamo should operate differently when [Formula: see text], the regime relevant to many astrophysical environments such as the intracluster medium of galaxy clusters. This paper reports an experiment that creates a laboratory [Formula: see text] plasma dynamo. We provide a time-resolved characterization of the plasma's evolution, measuring temperatures, densities, flow velocities, and magnetic fields, which allows us to explore various stages of the fluctuation dynamo's operation on seed magnetic fields generated by the action of the Biermann-battery mechanism during the initial drive-laser target interaction. The magnetic energy in structures with characteristic scales close to the driving scale of the stochastic motions is found to increase by almost three orders of magnitude and saturate dynamically. It is shown that the initial growth of these fields occurs at a much greater rate than the turnover rate of the driving-scale stochastic motions. Our results point to the possibility that plasma turbulence produced by strong shear can generate fields more efficiently at the driving scale than anticipated by idealized magnetohydrodynamics (MHD) simulations of the nonhelical fluctuation dynamo; this finding could help explain the large-scale fields inferred from observations of astrophysical systems.

Disparities in incidence and trends of colorectal, lung, female breast, and cervical cancers among non-Hispanic American Indian and Alaska Native people, 1999-2018.

PURPOSE: This study is the first to comprehensively describe incidence rates and trends of screening-amenable cancers (colorectal, lung, female breast, and cervical) among non-Hispanic AI/AN (NH-AI/AN) people. METHODS: Using the United States Cancer Statistics AI/AN Incidence Analytic Database, we, calculated incidence rates for colorectal, lung, female breast, and cervical cancers for NH-AI/AN and non-Hispanic White (NHW) people for the years 2014-2018 combined. We calculated age-adjusted incidence rates (per 100,000), total percent change in incidence rates between 1999 and 2018, and trends over this time-period using Joinpoint analysis. Screening prevalence by region was calculated using Behavioral Risk Factor Surveillance System data. RESULTS: Rates of screening-amenable cancers among NH-AI/AN people varied by geographic region and age at diagnosis. Over half of all lung and colorectal cancers in NH-AI/AN people were diagnosed at later stages. Rates of lung and colorectal cancers decreased significantly between 1999-2018 among NH-AI/AN men, but no significant changes were observed in rates of screening-amenable cancers among NH-AI/AN women. CONCLUSION: This study highlights disparities in screening-amenable cancers between NH-AI/AN and NHW people. Culturally informed, community-based interventions that increase access to preventive health services could reduce cancer disparities among AI/AN people.

Association of fractional exhaled nitric oxide with asthma morbidity in urban minority children.

OBJECTIVE: Fractional exhaled nitric oxide (FeNO) is a well-established measure of allergic airway inflammation and possible useful adjunct disease management tool. We investigated the association of baseline and follow-up FeNO measurements with disease burden in minority children with persistent asthma. METHODS: A retrospective chart review was conducted on 352 African American and Hispanic children seen at an urban Asthma Center in Bronx, NY. Demographic, clinical characteristics, and pulmonary function tests (PFTs) were compared between children with low, intermediate, and high baseline FeNO levels. Among 95 children with subsequent follow up visits, associations of change in FeNO with demographics, clinical characteristics, and PFTs were examined using mixed effects linear regression models. RESULTS: A higher proportion of children with intermediate (54%) and high FeNO (58%) levels had lower airways obstruction compared to those with low FeNO levels (33%). Children with intermediate FeNO levels had more annual hospitalizations (2.8 ± 6.2) compared to those with low and high FeNO levels (1.3 ± 2.8 and 1.3 ± 2.5). These associations did not differ between ethnicities. An increase in FeNO over time was associated with higher BMI z-scores (ß = 6.2, 95% CI: 1.0 to 11.4) and two or more hospitalizations in the past year (ß = 16.1, 95% CI: 1.5 to 30.8). CONCLUSIONS: Intermediate and high FeNO levels are associated with lower airways obstruction and hospitalizations. Initial and serial FeNO measurements can be a useful adjunctive tool in identifying asthma-related morbidity in urban African American and Hispanic children.

Cutaneous epitheliotropic lymphosarcoma in a captive white catfish (Ameiurus catus Linnaeus).

A wild caught white catfish (Ameiurus catus Linnaeus) developed multiple cutaneous masses. Cytology revealed neoplastic lymphocytes and microscopy confirmed dermal infiltration with epitheliotropism in the epidermis, oral mucosa, and cornea, without internal organ involvement. Transmission electron microscopy did not identify viral particles. Histopathology supported cutaneous epitheliotropic lymphosarcoma, a condition most commonly reported in mammals. This is the first reported case of cutaneous epitheliotropic lymphosarcoma in an ictalurid and one of the few published cases of this condition in any fish species.

Clinicopathologic, Gross Necropsy, and Histopathologic Effects of High-Dose, Repeated Meloxicam Administration in Rhode Island Red Chickens (Gallus gallus domesticus).

Meloxicam is a commonly prescribed non-steroidal anti-inflammatory drug for backyard poultry that has demonstrated pharmacodynamic efficacy at a single high dose of 5 mg/ kg. This study characterized the adverse effects of meloxicam administered in chickens at an approximate dose of 5 mg/kg orally twice daily for 5 days. Twenty-one adult Rhode Island Red hens (Gallus gallus domesticus), judged to be healthy based on an external physical examination, complete blood count (CBC), and plasma biochemistry panel, were recruited for this study. The subject birds were randomly assigned to a treatment (n = 11) or control group (n = 10) and received a 15-mg tablet of meloxicam or a nonmedicated feed pellet, respectively, orally twice daily. Physical examinations and body weight measurements were performed daily, and observation for clinical signs occurred twice daily. Following completion of the 5-day treatment course, an external physical examination, blood collection for a CBC and plasma biochemistry panel, euthanasia, necropsy, and measurement of meloxicam tissue residues were performed. During the treatment course, 1 hen from the treatment group died with peracute clinical signs, 2 hens from the treatment group died suddenly with no clinical signs, and 1 hen from the treatment group became acutely lethargic and was euthanized. Within the meloxicam group, 7 out of 11 hens had gross and histologic evidence of varying levels of renal acute tubular injury and gout. Plasma uric acid concentrations were above the species reference intervals in all affected hens in the treatment group that were still available for testing. The control group had no evidence of renal injury or gout based on postmortem examinations. Based on the results of this study, repeated oral dosing of meloxicam in chickens at 5 mg/kg twice daily is not recommended.

Drug Reaction with Eosinophilia and Systemic Symptoms and Agranulocytosis Presenting as Cervical Lymphadenopathy.

Objective: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare cause of cervical lymphadenopathy. It is a potentially life-threatening hypersensitivity reaction, commonly characterized by fever, rash, hematological abnormalities, and multi-organ involvement. Its association with agranulocytosis is even rarer, with fewer than 10 cases describing the coexistence of DRESS with agranulocytosis reported in the English literature. Case Summary: An otherwise well 40-year-old female presented with a sore throat and cervical lymphadenopathy, with investigations revealing DRESS and agranulocytosis secondary to carbamazepine. Conclusion: DRESS and agranulocytosis are serious, potentially life-threatening adverse drug reactions which can initially present as cervical lymphadenopathy. As carbamazepine is considered first-line therapy for certain chronic neuropathic conditions such as trigeminal neuralgia, clinicians should be aware of the varying clinical presentations of both conditions.

Host Genome-Wide Association Study of Infant Susceptibility to Shigella-Associated Diarrhea.

Shigella is a leading cause of moderate-to-severe diarrhea globally and the causative agent of shigellosis and bacillary dysentery. Associated with 80 to 165 million cases of diarrhea and >13% of diarrheal deaths, in many regions, Shigella exposure is ubiquitous while infection is heterogenous. To characterize host-genetic susceptibility to Shigella-associated diarrhea, we performed two independent genome-wide association studies (GWAS) including Bangladeshi infants from the PROVIDE and CBC birth cohorts in Dhaka, Bangladesh. Cases were infants with Shigella-associated diarrhea (n = 143) and controls were infants with no Shigella-associated diarrhea in the first 13 months of life (n = 446). Shigella-associated diarrhea was identified via quantitative PCR (qPCR) threshold cycle (CT ) distributions for the ipaH gene, carried by all four Shigella species and enteroinvasive Escherichia coli Host GWAS were performed under an additive genetic model. A joint analysis identified protective loci on chromosomes 11 (rs582240, within the KRT18P59 pseudogene; P = 6.40 × 10-8; odds ratio [OR], 0.43) and 8 (rs12550437, within the lincRNA RP11-115J16.1; P = 1.49 × 10-7; OR, 0.48). Conditional analyses identified two previously suggestive loci, a protective locus on chromosome 7 (rs10266841, within the 3' untranslated region [UTR] of CYTH3; Pconditional = 1.48 × 10-7; OR, 0.44) and a risk-associated locus on chromosome 10 (rs2801847, an intronic variant within MPP7; Pconditional = 8.37 × 10-8; OR, 5.51). These loci have all been indirectly linked to bacterial type 3 secretion system (T3SS) activity, its components, and bacterial effectors delivered into host cells. Host genetic factors that may affect bacterial T3SS activity and are associated with the host response to Shigella-associated diarrhea may provide insight into vaccine and drug development efforts for Shigella-associated diarrheal disease.

Contribution of systemic and airway immune responses to pediatric obesity-related asthma.

Childhood obesity contributes to many diseases, including asthma. Although the precise mechanism by which obesity causes asthma is not known, there is literature to suggest that innate and adaptive systemic and airway immune responses in obese children with asthma differ from those in normal-weight children with asthma. Both non-allergic or non-T2 phenotype with systemic T helper (Th)1 polarization and allergic Th cell responses have been reported in childhood obesity-related asthma. There is preliminary evidence to suggest that genetic and epigenetic mechanisms contribute to these immune responses. Initial investigations into the biology of non-T2 immune responses have identified upregulation of genes in the CDC42 pathway. CDC42 is a RhoGTPase that plays a key role in Th cell physiology, including preferential naïve Th cell differentiation to Th1 cells, as well as cytokine production and exocytosis. These novel pathways are promising findings to direct targeted therapy development for obesity-related asthma to address the disease burden.

Vaping Associated Pulmonary Nontuberculous Mycobacteria.

INTRODUCTION: E-cigarette or vaping product use associated lung injury (EVALI) has been an important health risk in both children and adults. The pathophysiology of EVALI is not well understood. However, it is speculated that certain substances such as Vitamin E Acetate (VEA), particularly in marijuana containing vape cartridges may result in lung injury and lead to respiratory dysfunction. EVALI is often seen in the absence of infections, but it has been found to be associated with both fungal and bacterial infections. Like EVALI, nontuberculous mycobacteria (NTM) pulmonary disease is also on the rise, but is primarily reported in immunocompromised individuals. Here, we present three immunocompetent individuals wherein pulmonary NTM infection co-occurred with vaping. METHODS: Medical information including patient history, laboratory, and radiograph reports were abstracted from electronic medical records from participating institutions located in the Bronx, NY, Philadelphia, PA, and Lexington, KY. RESULTS: All three cases were otherwise immunocompetent individuals with a significant history of vaping either nicotine and/or marijuana containing products. The pathogens isolated include Mycobacterium avium complex, M. xenopi, and M. gordonae. All three patients were treated for NTM. CONCLUSION: There is little reported on the association between vaping and NTM. It is possible that vaping may have rendered these individuals to be more susceptible to NTM colonization and infection. The possible mechanisms of vaping lung injury and pulmonary NTM are discussed.

Bullous amyloidosis in a horse: first description in veterinary medicine.

BACKGROUND: Bullous amyloidosis is a rare disease in humans that has not been described in a veterinary species in the peer-reviewed literature. The human disease is characterised by haemorrhagic vesicles and bullae on the skin and mucosae, which form due to amyloid deposition. HYPOTHESIS/OBJECTIVES: To describe the clinical features, laboratory analysis and histopathological features of an unique presentation of bullous disease in a horse. ANIMALS: A 17-year-old thoroughbred mare presented for weight loss and severe oral cavity ulcers. METHODS AND MATERIALS: Investigations involved haematological evaluation, chemistry profiles, gastroscopy and serum protein electrophoresis, and, postmortem, histopathological evaluation, Congo-red staining and transmission electron microscopy (TEM). RESULTS: Haemorrhagic vesicles and bullae occurred on the mucosa of the oral cavity, lips, oesophagus and stomach, and much less the muzzle, face and mucocutaneous areas of the perineum, where scarring was evident. Histopathological evaluation and Congo-red staining confirmed the presence of amyloid deposits in dermis and submucosa, in association with vesicle and bulla formation, consistent with bullous amyloidosis. TEM confirmed amyloid fibril deposition in the dermis and along the basement membrane zone. Clefts occurred in the superficial dermis and submucosa, which explained haemorrhage and scarring. The presence of a polyclonal gammopathy and the rapid abolishment of Congo-red staining with performate pretreatment supported serum amyloid A and secondary amyloidosis. CONCLUSION AND CLINICAL IMPORTANCE: Bullous amyloidosis is a novel disease of the horse and a newly recognised differential for bullous disease, for which the haemorrhagic nature of bullae, scarring and deep secondary ulcers are considered clinical clues to the condition.

Development of CDX-527: a bispecific antibody combining PD-1 blockade and CD27 costimulation for cancer immunotherapy.

CD27 is a costimulatory molecule that provides a complementary target to the PD-1/PD-L1 checkpoint axis on T cells. Combining a CD27 agonist antibody with PD-1/PD-L1 blockade has shown synergistic antitumor activity in preclinical models, which led to clinical studies of the combination in cancer patients. We theorized that coupling CD27 costimulation with PD-1/PD-L1 blockade in a bispecific antibody (BsAb) may provide greater immune activating properties than combining the individual mAbs due to enhanced CD27 activation by cross-linking through PD-L1 and Fc receptors. To test this approach, we developed CDX-527, a tetravalent PD-L1xCD27 IgG1-scFv BsAb. CDX-527 potently inhibits PD-1 signaling and induces CD27-mediated T cell costimulation through PD-L1 cross-linking. In mixed lymphocyte reaction assays, CDX-527 is more potent than the combination of the parental antibodies, suggesting that cross-linking through both Fc receptors and PD-L1 results in enhanced CD27 agonist activity. CDX-527 was shown to mediate effector function against tumor cells overexpressing either CD27 or PD-L1. In human CD27 transgenic mice, we observed that antigen-specific T cell responses to a vaccine are greatly enhanced with a surrogate PD-L1xCD27 BsAb. Furthermore, the BsAb exhibits greater antitumor activity than the combination of the parental antibodies in a syngeneic lymphoma model. A pilot study of CDX-527 in cynomolgus macaques confirmed a mAb-like pharmacokinetic profile without noted toxicities. These studies demonstrate that CDX-527 effectively combines PD-1 blockade and CD27 costimulation into one molecule that is more potent than combination of the parental antibodies providing the rationale to advance this BsAb toward clinical studies in cancer patients.

The role of Enterococcus faecalis during co-infection with avian pathogenic Escherichia coli in avian colibacillosis.

Enterococcus spp. (ENT) are frequently co-isolated with avian pathogenic E. coli (APEC) from poultry with colibacillosis, a leading cause of flock mortality. Although largely overlooked, ENT may play an active role in these infections. To assess the frequency of ENT co-isolation in colibacillosis, cultures were collected from birds with gross lesions of omphalitis, polyserositis, and septicaemia over a 3-year period from three turkey flocks and three broiler flocks. In birds diagnosed with colibacillosis based on gross findings and isolation of E. coli, ENT were co-isolated with APEC in 35.7% (n = 41/115) of colibacillosis mortality and 3.7% of total mortality (n = 41/1122). Co-isolated APEC and ENT pairs (n = 41) were further characterized using antimicrobial resistance phenotyping and in vitro co-culture assays. E. faecalis (EF) was the most commonly co-isolated species (68% n = 28/41) and tetracycline resistance was the resistance phenotype most commonly found among APEC (51% n = 21/41) and ENT (93% n = 38/41). Under iron-restricted conditions, EF enhanced APEC growth in a proximity-dependent manner and APEC grown in mixed culture with EF exhibited a significant growth and survival advantage (P ≤ 0.01). In an embryo lethality assay, APEC co-infection with EF resulted in decreased survival of broiler embryos compared to mono-infections (P ≤ 0.05). These data demonstrate that EF augmented APEC survival and growth under iron limiting conditions, possibly translating to the increased virulence of APEC in broiler embryos. Thus, ENT co-infections may be a previously unrecognized contributor to colibacillosis-related mortality. Further investigations into the mechanism of this interaction are warranted. RESEARCH HIGHLIGHTS Enterococcus is frequently co-isolated with avian pathogenic E. coli (APEC). Enterococcus faecalis (EF) enhances survival of APEC in iron restricted conditions. EF co-infection increases APEC virulence in broiler embryos.

Vaccination of breeder hens with a polyvalent killed vaccine for pathogenic Enterococcus cecorum does not protect offspring from enterococcal spondylitis.

Pathogenic strains of Enterococcus cecorum cause symmetrical paralysis in broilers due to infection of the free thoracic vertebra. The disease caused by pathogenic E. cecorum, known as enterococcal spondylitis or "kinky-back" continues to be responsible for significant losses to the broiler industry worldwide. In outbreaks of pathogenic E. cecorum, gut colonization and sepsis occur in the first three weeks-of-life. Since maternal antibodies are present during this period, we postulated that vaccination of breeders with a polyvalent killed vaccine would protect chicks from challenge. To test this hypothesis, representative isolates from seven genotype groups of pathogenic E. cecorum circulating in the US were chosen to produce adjuvanted killed vaccines (bacterins) and given to broiler-breeder hens. No single strain produced high titres of antibodies to all other strains; however, the combination of serologic reactivity of pathogenic isolates (designated SA3 and SA7) was sufficient to react with all genotypes. Vaccination of commercial broiler-breeder hens with a bacterin composed of SA3 and SA7 did not have any adverse effects. Vaccinated hens developed E. cecorum specific antibodies; however, no significant difference in survival was observed in infected embryos from hens in vaccine or adjuvant only groups. Chicks from vaccinated hens also failed to resist homologous or heterologous challenge during experimental infection. In a macrophage killing assay, pathogenic E. cecorum were found to evade opsinophagocytosis with elicited antibodies. These data suggest that pathogenic strains of E. cecorum possess virulence mechanisms that confound antibody-mediated opsinophagocytosis, complicating vaccine development for this pathogen of broilers.

Temporal characterization of wooden breast myopathy ("woody breast") severity and correlation with growth rate and lymphocytic phlebitis in three commercial broiler strains and a random-bred broiler strain.

Wooden breast myopathy (WBM), or "woody breast" or "wooden breast" affects modern, rapidly growing, high breast-yield broiler chickens. Decreased meat quality due to undesirable organoleptic properties and condemnation of affected breast meat cause economic losses. The pathogenesis of WBM remains unknown. In this study, WBM lesion development was determined in three modern broiler strains and Athens Canadian Random Bred (ACRB) broilers, a 1950s unselected broiler chicken. Correlations between WBM severity and incubation temperature profile, sex, strain, body weight, and lymphocytic phlebitis were also determined. At 2, 4, 6, and 8 weeks of age, samples of breast muscle from 10 male and 10 female birds from each strain, incubated under optimal or low-early, high-late temperatures, were scored histologically for severity of WBM and lymphocytic phlebitis. WBM lesions, identified as early as 2 weeks, became progressively more severe with age and growth in the three commercial broiler strains. WBM severity was significantly correlated with lymphocytic phlebitis and body weight. Lymphocytic phlebitis and minimal WBM were present in the ACRB broilers at all samplings, but did not progress in severity over time. There were no significant differences in severity of WBM among the commercial broiler strains, between sexes, or between incubation temperature profiles. The positive correlation between WBM severity and lymphocytic phlebitis indicates vascular injury is likely an important factor in the pathogenesis. Mild muscle lesions in ACRB birds without overt clinical signs indicate subclinical muscle disease may have been present in broilers prior to the description of WBM.

Prevalence and severity of osteochondrosis of the free thoracic vertebra in three modern broiler strains and the Athens Canadian Random Bred control broiler.

Osteochondrosis (OCD) results from a disturbance of endochondral ossification in articular cartilage and is an important cause of lameness in several animal species, including chickens. OCD lesions in the free thoracic vertebra (FTV) of chickens are essential to the pathogenesis of pathogenic Enterococcus cecorum. The goal of this study was to determine the prevalence of OCD in the FTV among three modern broiler chicken crosses (strains A/A, A/B, and C/C) and Athens Canadian Random Bred (ACRB) chickens, which served as the control group. The effect of sex, age, strain, body weight, and incubation temperature profile on OCD severity for each group was determined. At 2, 4, 6, and 8 weeks of age, the FTV of 10 male and 10 female birds from each strain exposed to either optimal or low-early, high-late incubation temperature profiles were collected and scored histologically for OCD lesion severity. OCD spectrum lesions were detected in >70% of all strain/sex combinations, including the ACRB controls. No association was observed between mean OCD score and broiler strain, incubation temperature profile, sex, age, or body weight. These findings indicate that OCD of the FTV is common in broiler chickens with similar prevalence observed in broilers with modern genetics and the ACRB broilers which represent 1950s broiler genetics. As the parameters examined did not have a statistical correlation with OCD, additional work is needed to understand factors that contribute to development of OCD in chickens.

Risk factors in early and late onset schizophrenia.

BACKGROUND: This study looks at key risk factors in patients with schizophrenia to identify trends according to age of onset, comparing presentations prior to 26years (youth onset), between 26 and 40years (middle onset), and after 40years of age (late onset). METHODS: The early psychosis program at St Vincent's Hospital Melbourne treats patients presenting in the early stages of psychosis between 16 and 65years of age. A database was developed to capture key risk factors in all patients with an eventual diagnosis of schizophrenia (n=225). Risk factor profiles were then generated and compared for patients based on age of onset. RESULTS: Older age of onset was associated with weaker family history of schizophrenia, lower rates of substance use, better early psychosocial functioning and higher educational achievement. Female preponderance and comorbid physical health problems were particularly notable in the late onset cohort. Later life schizophrenia also showed a relatively greater association with psychosocial factors proximal to psychosis onset, such as unemployment. DISCUSSION: Clear trends are noticeable with age. Older patients have characteristic differences in their background risk factors compared to youth onset patients, including less hereditary influence and relatively more emphasis on later life risk factors. Identifying the roles of specific risk factors in these distinct age-onset groups can enhance our understanding of underlying aetiology and facilitate service development to meet the needs of each specific age group.

Quality Improvement Initiative Enhances Outpatient Pediatric Pulmonology Follow-up for Premature Infants with Bronchopulmonary Dysplasia.

Introduction: Bronchopulmonary dysplasia (BPD) is a chronic lung disorder affecting many premature infants. Infants with BPD have higher hospital readmission rates due to respiratory-related morbidity. We aimed to increase the rates of outpatient pulmonary follow-up and attendance of premature babies with moderate and severe BPD to above 85% within 6 months. Methods: We conducted a quality improvement project at Yale New Haven Children's Hospital. Key interventions included developing a BPD clinical pathway integrated into the electronic medical record to assist providers in correctly classifying BPD severity, assigning the appropriate International Classification of Diseases, 10th Revision code (P27.1), and providing standardized treatment options. The outcome measures included correct diagnosis and classification of BPD, the percentage of patients with BPD scheduled for pediatric pulmonology appointments within 45 days, and the percentage attending those appointments. Results: There were 226 patients in our study, including 85 in the baseline period. Correct diagnosis of BPD increased from 49% to 95%, the percentage of scheduled appointments increased from 71.9% to 100%, and the percentage of appointments attended increased from 55.6% to 87.1%. Conclusions: Our quality improvement initiative improved the accuracy of diagnosis, severity classification, and outpatient pulmonary follow-up of children with moderate and severe BPD.